Recent Health Care Developments - new Medicaid options for HIV, breast and cervical cancer tre atment; help for paying Medicare Part B premium; Pennsylvania State Children's Health Program expansion approved; environmental causes of disease researched Health Care Financing Review, Spring, 2000• 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • Next Maine Medicaid Early HIV Treatment Plan Approved Health and Human Services (HHS) Secretary Donna E. Shalala recently approved Maine's demonstration plan to launch an early intervention and treatment program for individuals in need who are human immunodeficiency virus (HIV)-positive, but do not yet have acquired immunodeficiency syndrome (AIDS) and are not already eligible for Medicaid. Maine is the first State to offer a plan to en roll low-income HIV-positive individuals in the Medicaid program before they become disabled or impoverished. Recent research has shown that early intervention with AIDS-fighting drugs, including anti- retroviral therapies, can slow the progress of the disease and increase life expectancy for many HIV-positive individuals. However, many people with HIV generally do not qualify forMedicaid--the State/Federal partnership that provides health insurance to low-income young, aged, blind, and disabled Americans--until they are considered disabled. This demonstration program will make drug therapies and treatment services available to HIV-positive people earlierin the course of their disease, delaying the onset of disability for many of these individuals. "Since 1993, we have made unprecedented progress in the baffle against HIV and AIDS," Secretary Shalala said. "Better research, prevention, and treatment is helping people with this- disease live longer, healthier lives, even as we continue our search for a cure. I'm especially
Recent Health Care Developments - newMedicaid options for HIV, breast and cervical
cancer treatment; help for paying MedicarePart B premium; Pennsylvania StateChildren's Health Program expansionapproved; environmental causes of diseaseresearchedHealth Care Financing Review, Spring, 2000
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Maine Medicaid Early HIV Treatment Plan Approved
Health and Human Services (HHS) Secretary Donna E. Shalala recently approved Maine'sdemonstration plan to launch an early intervention and treatment program for individuals in needwho are human immunodeficiency virus (HIV)-positive, but do not yet have acquiredimmunodeficiency syndrome (AIDS) and are not already eligible for Medicaid. Maine is the firstState to offer a plan to enroll low-income HIV-positive individuals in the Medicaid programbefore they become disabled or impoverished.
Recent research has shown that early intervention with AIDS-fighting drugs, including anti-retroviral therapies, can slow the progress of the disease and increase life expectancy for manyHIV-positive individuals. However, many people with HIV generally do not qualify for
Medicaid--the State/Federal partnership that provides health insurance to low-income young,aged, blind, and disabled Americans--until they are considered disabled. This demonstrationprogram will make drug therapies and treatment services available to HIV-positive people earlier in the course of their disease, delaying the onset of disability for many of these individuals.
"Since 1993, we have made unprecedented progress in the baffle against HIV and AIDS,"Secretary Shalala said. "Better research, prevention, and treatment is helping people with this-disease live longer, healthier lives, even as we continue our search for a cure. I'm especially
pleased today to approve a new approach in Maine which can give more people living with HIVaccess to promising therapies
Early intervention is also expected to reduce the need for costly hospitalization and to preventthe onset of opportunistic infections. HHS will closely monitor the Maine demonstration toidentify any cost savings to Medicaid during the 5 years of the demonstration.
"By making treatment available early to people with HIV, we can vastly improve the quality of their lives," said Nancy-Ann DeParle, administrator of the Health Care Financing Administration(HCFA), which oversees the Medicaid program. "I'm pleased to be able to work with Maine topromote early treatment of HIV-positive individuals to help them cope with this devastatingdisease."
Since 1993, HHS has approved 18 comprehensive Medicaid demonstrations and several sub-State demonstrations, which have expanded health insurance coverage to more than 2 millionpeople. And last year, President Clinton signed the Ticket to Work and Work ImprovementIncentives Act, which creates an option for States to let Americans with disabilities buy in to theMedicaid program; extends Medicare coverage for people receiving disability insurancepayments who return to work; and creates an expanded Medicaid demonstration program to help
expand coverage to people with serious illnesses before they become disabled, to allow them tokeep working.
Maine's Medicaid agency plans to begin the 5-year demonstration project this September. To beeligible,-a participant must be HIV-positive and have an income of less than 300 percent of theFederal poverty level (the Federal poverty level is $8,350 for a person under age 65). The benefitpackage will include highly active anti-retroviral therapy, office visits, lab services, casemanagement, hospitalizations, and mental health and substance abuse services.
New Insurance Option to Cover Breast and Cervical Cancer
President Clinton recently announced a new health initiative to cover more uninsured womenwho have breast and cervical cancer. Specifically, his fiscal year (FY) 2001 budget will include a
new Medicaid option to provide insurance to the thousands of uninsured women whose breastand cervical cancer was detected through federally supported screening programs.
This investment of $220 million over 5 years will help bring down current and frequentlyoverwhelming financial barriers to treatment. The Vice President and the First Lady, as well asnational leaders in the prevention, diagnosis, and treatment of breast cancer, have been strongadvocates for this initiative. Similar legislation has received broad bipartisan support under theleadership of the late Senator Chafee, Senator Mikulski, Senator Snowe, and RepresentativesEshoo and Lazio.
For low-income women diagnosed with breast or cervical cancer, treatment options are limited.The National Breast and Cervical Cancer Early Detection Program provides breast and cervicalcancer screening to over 360,000 women without access to these services annually. Typically,
Federal Government-sponsored screening programs make every effort to assist individualsdiagnosed with disease to access treatment. However, thousands of women still face financialbarriers to care, and those that receive some help frequently do not receive comprehensivecoverage for services they need.
An estimated 2 million American women will be diagnosed with breast or cervical cancer in thisdecade, and half a million women will lose their lives to these diseases. According to the Centersfor Disease Control, approximately 15 to 30 percent of all deaths from breast cancer amongwomen over the age of 40 and virtually all deaths from cervical cancer could have been
prevented with early screening. When breast cancer is diagnosed early, the 5-year survival rate is97 percent; but when it is diagnosed after it has spread, the 5-year survival rate is only 21percent.
Early intervention is also expected to reduce the need for costly hospitalization and to preventthe onset of opportunistic infections. HHS will closely monitor the Maine demonstration to
identify any cost savings to Medicaid during the 5 years of the demonstration."By making treatment available early to people with HIV, we can vastly improve the quality of their lives," said Nancy-Ann DeParle, administrator of the Health Care Financing Administration(HCFA), which oversees the Medicaid program. "I'm pleased to be able to work with Maine topromote early treatment of HIV-positive individuals to help them cope with this devastatingdisease."
Since 1993, HHS has approved 18 comprehensive Medicaid demonstrations and several sub-State demonstrations, which have expanded health insurance coverage to more than 2 millionpeople. And last year, President Clinton signed the Ticket to Work and Work ImprovementIncentives Act, which creates an option for States to let Americans with disabilities buy in to theMedicaid program; extends Medicare coverage for people receiving disability insurance
payments who return to work; and creates an expanded Medicaid demonstration program to helpexpand coverage to people with serious illnesses before they become disabled, to allow them tokeep working.
Maine's Medicaid agency plans to begin the 5-year demonstration project this September. To beeligible,-a participant must be HIV-positive and have an income of less than 300 percent of theFederal poverty level (the Federal poverty level is $8,350 for a person under age 65). The benefitpackage will include highly active anti-retroviral therapy, office visits, lab services, casemanagement, hospitalizations, and mental health and substance abuse services.
New Insurance Option to Cover Breast and Cervical Cancer
President Clinton recently announced a new health initiative to cover more uninsured women
who have breast and cervical cancer. Specifically, his fiscal year (FY) 2001 budget will include anew Medicaid option to provide insurance to the thousands of uninsured women whose breastand cervical cancer was detected through federally supported screening programs.
This investment of $220 million over 5 years will help bring down current and frequentlyoverwhelming financial barriers to treatment. The Vice President and the First Lady, as well asnational leaders in the prevention, diagnosis, and treatment of breast cancer, have been strongadvocates for this initiative. Similar legislation has received broad bipartisan support under theleadership of the late Senator Chafee, Senator Mikulski, Senator Snowe, and RepresentativesEshoo and Lazio.
For low-income women diagnosed with breast or cervical cancer, treatment options are limited.The National Breast and Cervical Cancer Early Detection Program provides breast and cervical
cancer screening to over 360,000 women without access to these services annually. Typically,Federal Government-sponsored screening programs make every effort to assist individualsdiagnosed with disease to access treatment. However, thousands of women still face financialbarriers to care, and those that receive some help frequently do not receive comprehensivecoverage for services they need.
An estimated 2 million American women will be diagnosed with breast or cervical cancer in thisdecade, and half a million women will lose their lives to these diseases. According to the Centersfor Disease Control, approximately 15 to 30 percent of all deaths from breast cancer among
women over the age of 40 and virtually all deaths from cervical cancer could have beenprevented with early screening. When breast cancer is diagnosed early, the 5-year survival rate is97 percent; but when it is diagnosed after it has spread, the 5-year survival rate is only 21percent.
* Qualified Individual-2: New York State pays only part of the Medicare Part B premium ($2.87
per month) for Medicare beneficiaries with income from $960 to $1,238 (couples: from $1,286to $1,661) and savings up to $4,000 (couples: $6,000) plus money for burial expenses. Eligibilityfor this program will save beneficiaries $34.44 in 2000.
Individuals should immediately contact the Medicaid office of their local department of socialservices to apply for both Qualified Individuals programs. They should request an application for the Medicare Premium Payment Program. New York State has only a limited amount of moneyfor these programs and may have to limit the number of beneficiaries who can enroll.
In addition to the Qualified Individual programs, two other programs also pay the entireMedicare Part B premium for individuals with income up to $854 per month (couples: $1,144per month) and savings up to $4,000 (couples: $6,000) plus money for burial expenses. Applyingfor benefits is easy. A simple one-page application must be completed at the Medicaid office for
all of the above programs, except for the Qualified Medicare Beneficiary program (whichrequires completion of a Medicaid application).
The Brookdale Center on Aging has developed a new publication, 2000 Desk Guide to ProgramsWhich Pay Medicare Premiums, Deductibles, Coinsurance and Copayments, which includesinformation on all the programs that pay the Medicare Part B premium and other expenses facedby Medicare beneficiaries. Information about the Desk Guide is available by calling 518-433-9011 or 212-481-4433 or by visiting the website at www.brookdale.org.
Pennsylvania Expansion of State Children's Health Insurance Program Approved
HHS Secretary Donna E. Shalala recently approved a proposal by Pennsylvania to further expand its State Children's Health Insurance Program (SCHIP) and provide health insurance to
thousands of children who otherwise would not have coverage.State officials expect that the two amendments approved on March 7 will provide healthinsurance to an additional 16,000 children by September 2000. Through September 1999, theState had enrolled nearly 82,000 children.
Pennsylvania is eligible to receive as much as $117 million in funds for FY 1999. SCHIP ishistoric, bipartisan legislation signed in 1997 by President Clinton. The SCHIP law appropriates$24 billion over 5 years to help States expand health insurance to children whose families earntoo much for traditional Medicaid, yet not enough to afford private health insurance.Pennsylvania, like all States with approved SCHIP plans, will receive Federal matching fundsonly for actual expenditures to insure children.
As of September 1999, States have enrolled nearly 2 million children. SCHIP gives States threeoptions for devising a plan to cover uninsured children: designing a new children's healthinsurance program; expanding current Medicaid programs; or a combination of both strategies.HHS must approve any amendment to a State's SCHIP.
Families with incomes below 200 percent of the Federal poverty level are eligible for Pennsylvania's new program. The Federal poverty level is $17,050 for a family of four. There isno cost sharing for families in this program.
"Pennsylvania's amendments are a positive demonstration that SCHIP is working and that Statesare enthusiastic about this program," said Nancy-Ann DeParle, administrator of HCFA, whichadministers SCHIP. "It is through efforts like Pennsylvania's that we will realize theadministration's goal of providing health insurance to those who need it."
Government Initiative Seeks to Determine Environmental Causes of Disease
The White House recently announced that the President's FY 2001 budget will include anunprecedented funding increase to explore the largely unknown environmental causes of diseasesincluding breast and prostate cancer.
This major initiative, which is advocated by the American Cancer Society and the AmericanAcademy of Pediatrics, will provide $27 million, 56 percent greater than last year's fundinglevel, for the Centers for Disease Control and Prevention Environmental Health Lab to: assistcommunities in investigating unusual incidence of cancer or other diseases; identify regions of the country in which individuals are at increased risk of dangerous exposure to carcinogens andother toxic substances; and ensure rapid evaluation of the-impact of public health emergencies.Because of the lack of evidence pinpointing the environmental cause of cancers and many other diseases, these studies should play a major role in determining new, more effective diagnostic
tests and preventive techniques.
Studies tracking patterns of cancer development, birth defects, and other diseases suggest theinfluence of environmental contaminants.
Of the 120,000 U.S. babies born each year with a birth defect, 8,000 die during their first year of life, making birth defects the leading cause of infant mortality in the United States andcontributing substantially to childhood morbidity and long-term disability. Hundreds of thousands of cases of asthma and lead poisoning are also associated with environmentalcontaminants.
Initial scientific evidence demonstrates that increased risk of breast cancer may be associatedwith unknown environmental factors. According to the American Cancer Society, one out of
nine American women will develop breast cancer in her lifetime, and breast cancer is now theleading cause of cancer for women between the ages of 35 and 54. Despite decades of research,over half of all breast cancer cases cannot be explained by known risk factors, such as geneticpredisposition, reproductive history, and diet
In addition, initial scientific evidence demonstrates that increased risk of prostate cancer may beassociated with unknown environmental factors. Prostate cancer is the most common type of cancer found in American men other than skin cancer, and disproportionately impacts African-American men. Researchers estimate that there will be about 180,000 new cases of prostatecancer in the United States this year, 36 percent of all cancer cases, and that about 37,000 menwill die of this disease. However, researchers estimate that only 10 percent of prostate cancersare due to genetic predisposition.
Lack of research on the association between environmental exposure and breast cancer, prostatecancer, and other diseases represents a lost opportunity to improve public health. Research on theimpact of environmental contaminants on individual health will promote the development of improved diagnostic techniques, prevention strategies, and treatments. If exposure to chemicalsin the environment is shown to be associated with only 10 percent of breast and prostate cancer cases, and we reduce or eliminate the identified hazards, the development of these diseases in30,000 men and women could potentially be prevented each year.
The President's FY 2001 budget will include a $27 million investment to:
* Double the level of assistance provided to State and local public health officials investigatingadverse health events potentially linked to environmental exposures.
* Identify regions of the country where individuals are exposed to toxic sub. stances that causecancer and other diseases.
* Ensure rapid evaluation of the impact of public health emergencies.
Office-Based Medicaid Managed Care Physicians Serve Few Medicaid Patients
According to an analysis by the United Hospital Fund, the majority of office-based physicians inNew York City who participate in Medicaid managed care plans serve very few Medicaidpatients.
The analysis, released in the Fund's publication Medicaid Managed Care Currents, reports thatalthough slightly more than one-half (54 percent) of the 4,352 physicians participating inMedicaid managed care plans are office-based physicians, these physicians see only-34 percentof Medicaid managed care patients.
Moreover, Currents reports that Medicaid managed care beneficiaries who are seen by office-based physicians are highly concentrated among a small subset of these doctors. Twenty-nine
office-based physicians are primary care providers for more than one-quarter of all Medicaidmanaged care beneficiaries enrolled with office-based providers in New York City. Two-thirdsof the city's Medicaid managed care enrollees--estimated at nearly 400,000 as of December 1997--receive care from doctors in clinics and other institutions.
According to Currents, office-based physicians tend to have more contracts with commercialmanaged care plans (health maintenance organizations) and play a more significant role withplans that are not provider-sponsored. In recent months, these types of commercial plans havebeen leaving the Medicaid program.
Under the current Medicaid fee-for-service system, office-based physicians play an importantrole as providers of care for Medicaid patients, particularly for children: one in every two (49percent) visits for children in fee-for-service Medicaid is provided by an office-based physician.The share for adults is smaller--one in every four (25 percent) adult visits is provided by anoffice-based physician.
The analysis of Medicaid managed care participation patterns of office-based physicians is basedon 1997 data provided by managed care plans to the State and the city and maintained in theHealth Provider Network file.
The summer issue of Currents also reports on trends and outlook for "enabling" services athospital-sponsored and freestanding ambulatory care sites. Such services--which includeoutreach, eligibility planning, case-management, transportation, child care, and other activities--enable low-income persons to seek medical care and successfully complete a course of treatment.
Medicaid Managed Care Currents is a quarterly publication tracking developments in New York
City's Medicaid managed care program. It is based on research and analytic work of the NewYork Consortium for Health Services Research, a collaborative undertaking of the UnitedHospital Fund, Columbia University, and New York University.
Children's Health Insurance Program Now Reaching Two Million
Nearly two million children who would otherwise be without health insurance coverage wereenrolled in the SCHIP in FY 1999--double the number reported for the first full year of theprogram.
The new enrollment figures, a total of 1,979,450 children, are based on State-by-State reporteddata on the number of children served from October 1, 1998-September 30, 1999. Of the 56approved State and U.S. territorial children's health insurance programs to date, 53 wereimplemented and operational during FY 1999. Of the nearly two million children covered as of September 30, 1999, States reported that over 1.2 million children were in new SCHIPs andalmost 700,000 were enrolled in Medicaid expansion plans. Both options are allowable under theSCHIP.
HHS has also approved 37 State plan amendments to date, many of which expand SCHIPeligibility to even more children. Several of these amendments were in effect during FY 1999,but many more will be implemented in the coming months providing health insurance toadditional children.
Recent Health Care Developments - newprocedures to cuts costs in health servicesHealth Care Financing Review, Winter, 2000
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HHS Announces Electronic Standards to Simplify Health Care Transactions
Health and Human Services (HHS) Secretary Donna E. Shalala recently announced standardformats to streamline the processing of health care claims, reduce the volume of paperwork, savethe U.S. health care system billions of dollars, and provide better service for providers, insurers,and patients.
The new standards, described in a regulation to be published in the Federal Register, establishstandard data content and formats for submitting electronic claims and other administrativehealth transactions. All health care providers will be able to use the electronic format to bill for their services, and all health plans will be required to accept these standard electronic claims,referral authorizations, and other transactions.
"From the beginning of this Administration, President Clinton has been committed to using newtechnology to benefit both the American people and American business. This is just the latest ina series of actions by the Clinton Administration that improve quality and efficiency while also
cutting costs and protecting privacy," Secretary Shalala said. "These standards are importantsteps toward a faster, simpler, less costly and more efficient health care system. Working closelywith the private sector, we have developed standard electronic formats to replace today's costlyand complex forms."
By promoting the greater use of electronic transactions and the elimination of inefficient paper
forms, the administrative simplification regulations are expected to provide a net savings to thehealth care industry of 829.9 billion over 10 years.
The proposed regulation was required by the Health Insurance Portability and Accountability Act(HIPAA) of 1996. In developing the proposal, HHS consulted extensively with private-sector organizations and individuals and published a preliminary rule in 1998. More than 17,000 publiccomments on the proposal were received.
HHS will take additional steps, issuing further regulations under HIPAA authority to improve theprocessing of health care transactions. These regulations will establish national identificationnumbers for employers and health care providers to speed claims processing and lower costs. Inaddition, HHS will lay out steps to make electronic health data secure, and protect the privacy of patients' medical and health insurance records. This will be done without the need for unique
personal identifier for individual patients.
By law, health plans--with the exception of small, self-administered plans--health careclearinghouses, and health care providers that choose to transmit their transactions in electronicform, must comply with these rules within 26 months from the date of publication of this finalrule, except that small health plans have an additional year in which to comply.
"These new standards are a win-win for health care providers and their patients," said Nancy-Ann DeParle, administrator of the Health Care Financing Administration, which runs theMedicare and Medicaid programs. "Information exchange will be more efficient and accurate,and providers will be able to spend less time on paperwork, and more time on the health care of their patients."
Secretary Shalala cautioned that this rule is being released under the assumption that privacyprotections will be in place at approximately the same time the rule takes effect. By thecompliance date, HHS expects that its regulation on privacy of medical records will also be ineffect, or Congress will have enacted such protections.
Health Status "Snapshot" of U.S. Counties Now on Web
Officials and residents in 3,082 U.S. counties can now access a web-based snapshot of their county's health status, HHS recently announced. Causes of deaths, infectious diseases, teenmothers, and a host of other indicators from existing national data sets can be found atwww.communityhealth.hrsa.gov.
This unique source of data is found in the Community Health Status Indicators (CHSI) reportsfunded by HHS' Health Resources and Services Administration (HRSA) and produced incollaboration with the National Association of County and City Health Officials, the NationalAssociation of State and Territorial Health Officials, and the Public Health Foundation. The datacover the period from 1988-1998.
"We encourage counties to compare their health status with the Nation and peer counties' withsimilar characteristics and challenges, identify strengths and areas needing improvement, andshare solutions for improving public health," said HRSA Administrator Claude Earl Fox, M.D.,M.P.H. "In responding to requests from local and State public health leaders for more data, we
wanted the project to be a bottom-up effort, with city, county, State, and public healthrepresentatives involved in producing the reports and helping to guide the process. Communityplanning efforts have historically been hindered by the lack of comprehensive data at the locallevel. The CHSI reports help to fill this gap, but do not serve as a substitute for rigorouscommunity needs assessment."
Birth outcomes, including low-birth-weight babies, unmarried mothers, and prenatal care, as wellas death data, including breast cancer, homicide, and heart disease, can be compared with peer counties, the Nation, and Healthy People 2010 targets.
HRSA sends some $4.7 billion annually to communities and States for health centers, humanimmunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) primary care andsupport services, maternal and child health programs, and training of a diverse healthprofessions' workforce for medically underserved communities. Its 100-Percent Access and ZeroHealth Disparities program is supporting some 200 communities building public/private sector coalitions and leveraging existing resources to improve access to care.
Early and Aggressive Type 2 Diabetes Treatment Urged
More than 2 dozen major studies show that health care providers and people with type 2 diabetesneed to take early and aggressive action to reduce the disability and premature deaths fromdiabetes-related diseases.
The July 19, 2000 Journal of the American Medical Association (JAMA) includes this urgentmessage by the National Diabetes Education Program (NDEP), a joint initiative of the NationalInstitutes of Health and the Centers for Disease Control and Prevention.
"Despite the availability of simple diagnostic tests, studies show that a person can have type 2diabetes for 9 to 12 years before it is discovered," said Charles M. Clark, Jr., M.D., chairman of the NDEP. During these years, harmful changes are already occurring, causing 15-20 percent of people to have eye damage and 5-10 percent to have kidney disease at the time of diagnosis.
Treating type 2 diabetes early is especially important. "We now know that blood glucose control
appears to be most effective in preventing the onset of diabetes complications," stated Dr. Clark."People who already have diabetes complications also deafly benefit from improved blood sugar control."
According to the NDEP's commentary, scientific evidence shows that improved blood sugar control provides both long-term benefits in reducing the risk or severity of eye, kidney, andnerve complications, as well as more immediate short-term benefits. "When people with diabetesbring down their high blood sugar levels even by modest amounts, in just a matter of weeks, theyfeel better, have more energy, and lose fewer days of work," said Dr. Clark.
Despite the significant improvements in health outcomes produced by aggressive diabetesmanagement, the latest national data show that more than one-half of people with diabetes in theUnited States have hemoglobin A1c (or A-1-C) levels above 7 percent, the level recommendedas the goal for people with diabetes. Hemoglobin Al c testing is the best way to measure aperson's average blood sugar level over the previous 3-month period. Yet, according to thecommentary, the test is not being used widely in clinical practice to treat and manage diabetes.
Treating diabetes requires a plan to control blood pressure, blood cholesterol, and blood fats (or lipids) as well as blood sugar. All of these factors play a role in controlling diabetes and reducingrisk of heart disease and stroke, the leading causes of death in people with diabetes. A proactive
India is probably the most diverse country in the world. With 22 official languages, close to
200 spoken languages and a thousand dialects, and each region having its distinct culture,
tradition and lifestyle, India may be considered as several countries within one. Sixty-two
years after gaining Independence from the British Colonial rule, India has persisted as the
largest democratic nation in the world. With a population of over 1.15 billion (WHO, 2008),
India is the second most populous country in the world. With an area slightly more than one-
third the size of US, India stands as the seventh largest country in the world, and houses 17
% of the world’s population. Seventy- one percent of this population lives in villages. The sex
ratio of the population which is heavily skewed in favor of men (948 women per 1000 men)
has been a matter of concern (WHO, 2006). The preamble of the Constitution of India
describes it as a sovereign, socialist, secular, democratic, republic. The Indian republic
consists of 28 states and 7 union territories with a parliamentary form of democracy. Though
for several decades post-independence India was more drawn towards socialism given its
strong ties with the Soviet Union, an economic crisis in the early 1990s saw liberalization
and market based reforms in the Indian economy. Despite the fact that the communist left
ideology has prevailed in couple of states, namely Kerala and West Bengal, the country has
a whole has transitioned towards globalization, and the last two decades have seen an
average economic growth rate of 5.8 % per annum, and almost 8.4% in 2006-07 (WorldBank, 2008). With a GDP of 1.089 trillion dollars, India is the 12th largest economy in the
world (4th largest considering purchasing power parity). Despite economic strides India is
facing problems of inequitable distribution of wealth across different regions and social
strata. As of 2005, 28.3% of India’s population lived below poverty line (National Health
Profile, 2007). While certain states have made significant socio- economic progress, some
have lagged behind. The states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh have
health care statistics significantly poorer than the national average (Ibid). One of India’s
strength would be its growing middle class, which is expected to be two-third of the
population by 2009-10 (Ibid). As a greater percentage of the population moves into this
bracket, it is expected that their health care needs and demands are likely to increase.
Current Health Status
The life expectancy at birth is 63 years; 62 years for males and 63 years for females (WHO,2006). This is a significant improvement given the fact that at the time of independence, the lifeexpectancy was just over 33 years. The maternal mortality rate is 4.5 per 10,000 live births(Ibid). One of the reasons for high MMR is that only 37.5 % of deliveries in rural areas and 73.5% in urban areas are conducted by skilled health professionals (Ibid). Malnutrition amongchildren is another problem, and reportedly 43.5 % of children under 5 years are malnourished.With respect to disease burden, India bears a stamp of both developing and developed countries.Infectious and parasitic diseases still remain a major problem, and account for 33% of all deaths.With 17% of the global population, India accounts for 20% of the total global disease burden,23% of the child deaths, 20% of the maternal deaths, 30% of Tuberculosis cases, 68% of Leprosy cases, and 14% of HIV infections. (NRHM, 2005)
The HIV prevalence rate is around 0.7% (WHO, 2006); and though much lower than Africancountries, is still a matter of concern. Deaths due to infectious diseases have progressivelydeclined over years. Urban sedentary lifestyle, changes in dietary habits and stress have allcontributed to an increase in prevalence of chronic diseases such as coronary heart disease,obesity, stroke and diabetes. Almost 41 million Indians are diabetics and the number is expectedto increase to 73.5 million by 2025 (PWC, 2007). The incidence of diabetes among urban adults
was 2.1% in the 1970s, and now it is up to 12.1%, the incidence being much higher in southernstates as compared to northern states (Ibid).
Traditionally the Indian health care system has been more focused on curative rather thanpreventive aspects of medicine. The burgeoning middle class, changing spectrum of diseasesassociated with western lifestyles, and increasing disparities among states and social classes are
all challenges that the Indian health system will have to address in the future.Applying the Roemer’s model to the Indian Health care system Developed by Dr. MiltonRoemer, the Roemer model analyzes health care systems from the perspectives of “organizationof programs and their management, the production of resources that support the system, thesources of economic support, and how services are delivered” (Barton 2003, 5). It is a model thathelps to analyze health systems from a holistic perspective and also facilitates an effectivecomparative analysis of different health systems around the world (Ibid.)
Organization of programs and their management For a country as diverse as India, theorganization and management is very much centralized. At the national level, three chief agencies oversee the administration of the healthcare system: The Ministry of Health and FamilyWelfare (MOHFW); The Directorate General of Health Services (DGHS); and The Central
Council of Health and Family Welfare (CCHFW) (MOHFW, 2008).
Health administration in India is governed by the Ministry of Health and Family welfare whichhas three departments – the Department of Health, the Department of Family Welfare, and thedepartment of AYUSH (Ayurveda, Unani, Siddha, and Homeopathy) (Ibid). The DGHScomprises of three main units – medical care and hospitals, public health, and generaladministration. Similarly, at the State level the administration is overseen by the State Ministryof Health, and the State Health Directorate. The Central administration offers direction andguidance to the network of state ministries for actual implementation. The CCHFW whichcomprises of health ministers and secretaries from all Indian states is the primary advisory andpolicy making body for healthcare in India. It promotes coordination between the Center and theStates in all matter concerning implementation of programs and measures pertaining to health.
(SEARO, 2008) The states further are divided into districts, each district having its ownadministrative apparatus. The district level structure of health services acts like the middlemanagement between the states on one side, and the peripheral services on the other. Recently,many states have taken efforts to bring all programs in a district under unified control. (SEARO,2008) The Indian Council of Medical Research (ICMR) is the national research organization.Similar councils for the AYUSH disciplines are concerned with research in their respectivefields. The Medical Council of India (MCI) is a national body that concerns itself with regulationof medical education and medical practice, accreditation of colleges, registration of physicians,and laying down code of medical ethics. Similarly, State Medical councils exist in individualstates. The healthcare framework also includes several national autonomous bodies that focus onspecific diseases and issues, namely National AIDS Control Organization (NACO), Nationaltuberculosis institute, National Institute of Mental Health and Neurosciences (NIMHANS),among others. (MOHFW, 2008)
Very recently, in 2008, the Public Health Foundation of India (PHFI) was launched as a public-private initiative to boost the research, training and policy development in the area of publichealth (IndianExpress.com, 2008). The PHFI, which has collaborated with several schools of public health in US and UK, has set up five centers of excellence that will produce 1000graduates of public health every year.
Centralized health planning in India is an integral part of the national socio-economic planning(Park & Park, 1991). Dating back to 1946, committees have been formed by the government of India from time to time to review the existing health situation and recommend measures for action. Germane to the planning process, are the five-year plans that are chalked out on aperiodic basis (Ibid). An outcome of the last 5 year plan was the National Rural Health Mission(2007-12) that seeks to reform the rural health care infrastructure (NRHM, 2007).
Economic support for health services
In the year 2005, the total expenditure on health was 5% of the GDP. As of 2007, the total valueof the healthcare sector was 34 billion dollars, with a per capita healthcare spending of just about$34 (100$ by PPP). India ranks 171st out of 175 countries in percentage of GDP spent in thepublic sector on health and 17th in private-sector spending (Mullan, 2006).
India has one of the highest spending by the private sector in the world, accounting to close to81% of the total health care spending. The share of government spending was close to 19%. Thepublic health expenditure was close to 0.9% of the GDP, well below the average of 2.8% for low- and middle-income countries, and the global average of 5.5% (NRHM, 2007).The National
Rural Health Mission (NRHM) launched in 2005 shows the commitment of the Indiangovernment to increase the health care spending from 0.9% to 2-3% of the GDP (Ibid).
Majority of the costs of treatment are met by out-of-pocket expenditures, estimated at 84.6% of total health care expenditure. This has serious consequences for the poor who spendproportionally higher on health care as compared to the rich. According to a World Bank study,out-of-pocket expenses may push 2.2% of Indians below the poverty line in a year. Thepenetration of health insurance is very low. It is estimated that around 11% of the population hasany form of health insurance. Less than 1% of the population has any form of private healthinsurance. Group insurance accounted for 35% of the total health insurance business (PWC,2007). The government or state health insurance schemes include the Central GovernmentHealth Scheme, and Employee State Insurance scheme. In addition there are several communitybased insurance schemes run by NGOs in certain states which may cover about 30 millionpopulation (Devadasan, Ranson, Van Damme, & Criel, 2004). At least 20 such schemes weredocumented as of 2004 covering a target population of anywhere between a few thousands to 2.5million (Ibid). Very recently, in April 2008, the National Health Insurance Program waslaunched under which families earning less than $100 per month could avail of health insurancefor a premium of less than $1 per year that would offer them a coverage of Rs 30,000 ($700) for hospital care (WSJ.com, 2008). The program that would benefit families living below povertyline saw an enrollment of 1.5 million by August 2008 and expected to enroll 12 millionindividuals by April 2009 (Ibid).
On January 1st 2007, the Insurance Regulatory and Development Authority (IRDA) eliminatedthe tariffs on general insurance (IBEF, 2008). This is expected to provide a boost to the privateinsurance industry which is can now adopt scientific rating and risk management practices tocome up with better products for their consumers. According to a study by the chamber of commerce, the private insurance market is expected to grow to $5.75 billion by 2010 .(Ibid)
Production of healthcare services
The educational infrastructure in India includes medical colleges (offering MBBS degree), post-graduate training institutions, dental colleges (offering BDS and MDS degrees), AYUSHinstitutes, nursing courses and paramedical courses. In the last 15 years, medical educationinfrastructure has grown rapidly. As of 2005, there were 229 medical colleges in India. This
number had increased to 266 by 2007-08, and the total intake of MBBS graduates was 30,290(NHP, 2007).There were 1,597 Institution for General Nurse Midwives with admission capacityof 59138 and 461 colleges for Pharmacy (diploma) with an intake capacity of 27735 during2006-07 (Ibid). As of 2005, there were 660,801 allopathic doctors registered with MCI; a ratio of 0.7 doctors per 1000 population, a number that is way below the global average of 1.5 doctorsper 1000 population (Ibid). The situation is worse in rural areas where fewer than 20 percent of the doctors, and 3 percent of the specialists practice (NHP, 2007). In addition to allopathicdoctors, there were 724,823 practitioners of AYUSH disciplines. Given the shortage of allopathic doctors there is a rationale for incorporating these practitioners of alternative medicineinto mainstream healthcare.
The service delivery infrastructure in health includes allopathic hospitals, AYUSH hospitals,community health centers (CHCs), Primary health centers (PHCs), sub-centers, blood banks,mental (psychiatric) hospitals, and cancer hospitals. (Park & Park, 1991). The Bhore Committeein 1946 laid the foundations for the rural health programme. Ever since, a vast public healthinfrastructure has been built. The norms are to have a CHC for 100,000 population, a Primaryhealth center for every 30,000 population and a sub-center for every 5000 population. At thevillage level, health care is primarily provided through voluntary health workers and healthassistants (Ibid). As of 2005, India had 3222 CHCs, 23,109 PHCs and 142,655 sub-centers.Shortage of skilled staff, low levels of motivation, inadequate funding and supplies have led to agross underutilization of these services. ( rural india paper) The number of unqualifiedpractitioners of various disciplines almost equals the number of registered practioners (Indiahealth report pg 25).About 75% of health infrastructure, medical man power and other healthresources are concentrated in urban areas where 27% of the population live (Patil,Somasundaram, & Goyal, 2002).
There were close to 10,000 hospitals in urban areas and 7000 in rural areas, with roughly500,000 and 150,000 beds respectively. The ratio of 1.7 hospital beds per thousand population inurban areas and 0.09 beds in rural areas is considered to be grossly insufficient. (PWC) India hasemerged as a major supplier of several bulk drugs, producing these at lower prices compared to
formulation producers worldwide. Several multinational companies have outsourced their manufacturing operations to India. By 2010, India could be producing 15% of the world’s bulk pharmaceuticals and drug intermediates. The private sector accounts for 82% of outpatient careand 56% of non-delivery admissions. (NHP, 2007) The private health care sector has grownsignificantly in the last decade. Focused primarily on the tertiary and secondary health caresegment, it has seen major investments through multi- specialty hospitals and nursing home.Owing to the cost advantage, India is being seen as a favorable destination for elective surgeryby foreign nationals. According to a joint study by the Confederation of Indian Industry andMcKinsey, Indian medical tourism was estimated at $350 million in 2006 and has the potential togrow into a $2 billion industry by 2012 (McKinsey, 2008).
Diagnostic and imaging clinics are common in urban areas, and several hub and spoke models
have emerged in the last few years that incorporate centralized testing labs and peripheralcollection centers. More recently, the big players from the tertiary segment, namely Manipal,Apollo and Fortis have entered into the primary health care segment through retail health careclinics with a focus on preventive medicine. So far, the clinics have focused on the upper segment of the population, and the concept of wellness is limited to health screenings, beautyand lifestyle products. Health promotion and health education as an integral component of healthcare delivery, in the strictest sense, is seen lacking.
Recent developments in health informatics and telemedicine are promising. Telemedicine is seenas an effective way of providing specialist care to the large rural population which has access toonly 3% of the specialists. Major hospitals like Apollo, Asian Heart Institute, NarayanHrudralaya, AIIMS, and Aravind Eye hospitals have adopted telemedicine, and have entered intopublic-private partnerships.
Summary
India is a country of great contrasts. Even though the private health sector in India has madesignificant strides in the last decade, there still are a lot of challenges that need to be met. Theincreasing disparities, re-emergence of infectious diseases, and changing disease spectrum, in asystem that is more ‘disease centric’ than ‘health centric’, are all likely to pose major hurdles.Reforming the Indian healthcare system calls for a paradigm shift from a ‘biomedical model’ to a‘socio-behavioral’ model focusing on health promotion and disease prevention. Also for acountry so remarkably diverse as India, the process of planning is very centralized. Hence it isnot surprising that policies on paper, however good they may be, fail to get implemented atgrass-root levels. A more decentralized system of planning and administration which wouldallow states and local districts more autonomy would be desirable. It is also interesting to note
that despite the shortcomings in the US healthcare system, it is often seen in India as a model toemulate, at least by the private health sector. The entry of multinational insurance companies,rise in third party administrators, and corporatization of hospitals are indicators that the futurehealth care system in India is more likely to resemble that of capitalistic economies. Whilemodernization of healthcare services and advances in technology are welcome changes, it shouldnot be at the expense of Primary Health Care. India may be much better off by adopting modelsfrom other developing countries that have made significant progress in health care, for instanceSri Lanka. Though there is no doubt that the Western influence will continue to pour in, and theWest will continue to use India for its affordable services by way of medical tourism, it will beIndia’s imperative to ensure that such progress does not isolate the bottom of the pyramid inIndia’s socio-economic heirarchy. The Indian health care system is in a state of transition. Strong
economic growth in years to come, coupled with the rising middle class will undoubtedly createan increased demand for health care services. As the health care system evolves to meet thisdemand, it must focus not merely on processes but also on outcomes. An appropriate health caremodel for India would be one that focuses primarily on ‘community-based primary health care of all’ rather than expensive specialized tertiary care which may benefit only a
