Health and Family Welfare and The Development of Health Infrastructure

Health Status of India

Government Initiatives

Reproductive, Maternal, Neonatal, Child and Adolescent health

• Janani Shishu Suraksha Karyakaram (JSSK)
• Rashtriya Kishor Swasthya Karyakram(RKSK)
• Rashtriya Bal SwasthyaKaryakram (RBSK)
• Universal Immunisation Programme
• Mission Indradhanush / Intensified Misson Indradhanush
• Janani Suraksha Yojana (JSY)
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
• NavjaatShishu Suraksha Karyakram (NSSK)
• National Programme for Family planning

National Nutritional Programmes

• National Iodine Deficiency Disorders Control Programme
• MAA (Mothers’ Absolute Affection) Programme for Infant and Young Child Feeding
• National Programme for Prevention and Control of Fluorosis (NPPCF)
• National Iron Plus Initiative for Anaemia Control
• National Vitamin A prophylaxis Programe
• Integrated Child Development Services (ICDS)
• Mid-Day Meal Programme

Communicable diseases

• Integrated Disease Surveillance Programme (IDSP)
• Revised National Tuberculosis Control Programme (RNTCP)
• National Leprosy Eradication Programme (NLEP)
• National Vector Borne Disease Control Programme
• Programme for Prevention and Control of leptospirosis
• National AIDS Control Programme (NACP)
• Pulse Polio Programme
• National Viral Hepatitis Control Program   
• National Rabies Control Programme  
• National Programme on Containment of Anti-Microbial Resistance (AMR)

Non-communicable diseases

• National Tobacco Control Programme(NTCP)
• National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS)
• National Programme for Control Treatment of Occupational Diseases
• National Programme for Prevention and Control of Deafness (NPPCD)
• National Mental Health Programme
• National Programme for Control of Blindness& Visual Impairment
• Pradhan Mantri National Dialysis Programme
• National Programme for the Health Care for the Elderly (NPHCE)
• National Programme for Prevention & Management of Burn Injuries (NPPMBI)
• National Oral Health programme

Health system strengthening programs

• Ayushman Bharat Yojana
• Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) 
• LaQshya’ programme (Labour Room Quality Improvement Initiative) 
• National Health Mission
• National Digital Health Mission (NDHM)

1. Janani Suraksha Yojana (JSY)

a demand promotion and conditional cash transfer scheme is implemented with the objective of reducing Maternal and Infant Mortality by encouraging institutional deliveries.

2. Janani Shishu Suraksha Karyakram (JSSK)

every pregnant woman is entitled to free delivery, including cesarean section in public health institutions. This also includes free transport, diagnostics, medicines, other consumables, food and blood, if required.

3. Pradhan MantriSurakshitMatritvaAbhiyan (PMSMA)

It aims to provide fixed-day assured comprehensive and quality antenatal care universally to all pregnant women on the 9^th of every month.

While antenatal care is routinely provided to pregnant women, special ANC services are provided by OBGY specialists/ Radiologist/ Physicians at government health facilities under PMSMA.

4. ‘LaQshya – Labor room Quality improvement Initiative’ has been launched on 11^thDec 2017.
5. Special provision of birth waiting homes under NHM in tribal areas.
6. Maternal Death Surveillance and Response (MDSR) is implemented to take corrective action for averting maternal deaths.
7. Maternal and Child Health (MCH) Wings are established at high caseload facilities.
8. Operationalization of Comprehensive Abortion Care Services and services for Reproductive Tract Infections and Sexually Transmitted Infections (RTI/STI).
9. Mother and Child Tracking System (MCTS) and Mother and Child Tracking Facilitation Centre (MCTFC), a name-based web-enabled system to track every pregnant women and child.

Health care infrastructure – Challenges

Fund Allocation & Inadequate Infra

The gap in fund management by the administrations should be understood and be balanced. Not enough funds are allocated for public healthcare in India and the inequality in urban and rural facilities is well known. Due to the lack of modern quality healthcare in the public sector, generally, people prefer private healthcare which is not affordable for most of the rural population due to lower-income and lack of basic insurance policy. Private healthcare in India is a premium and expensive affair for a large section of society. Notably expensive medical device is procured but basic infra is missing in public healthcare system.

Lack of infrastructure

India has been struggling with deficient infrastructure in the form of lack of well-equipped medical institutes for quite a while now. To add to it, the rate of building such medical teaching or training facilities remains less as compared to the need of the hour.

Optimal Insurance based service a Challenge

Insurance as a concept and its usefulness is still not understood in India due to which the insurance market in the country remains largely under-penetrated. Awareness campaigns and the government’s schemes such as Ayushman Bharat, Employment State Insurance, etc. have immensely helped in bringing insurance inclusiveness and enabling a large population in India to avail financial security cover on healthcare costs. However, with a large number of centre and state-specific insurance schemes comes the healthcare delivery and service challenges for the public sector healthcare system.

Shortage of efficient and trained manpower

One of the most pressing problems in India remains a severe shortage of trained manpower in the medical stream, this includes doctors, nurses, paramedics and primary healthcare workers. The situation remains worrisome in rural areas, where almost 66 per cent of India’s population resides.

The doctor-to-patient ratio remains abysmally low, which is merely 0.7 doctors per 1,000 people.

This is compared to the World Health Organisation (WHO) average of 2.5 doctors per 1,000 people. Improving this situation continues to remain a long-term process.

Unmanageable patient-load

Even prior to the outbreak of the Covid-19 pandemic, healthcare facilities had been feeling the strain due to unmanageable patient-load. Moreover, serving a population of 1.4 billion remains a Herculean task in itself when it comes to suitably managing healthcare facilities.

There is a need to adopt technology wherever possible to streamline the operational and clinical processes for healthcare facilities in order to manage efficient patient flow. In addition, there is the challenge to think beyond the obvious and promote virtual care protocols, and telehealth services, which can be leveraged to reduce the patient-load burden to a large extent.

Public health policy and proactive healthcare

The latest National Health Policy (NHP) 2017 highlights the ‘Health for All’ approach to provide assured healthcare for all at an affordable cost. However, there is scope to do much more under the NHP 2017. Ideally, the public health policy needs to be focussed towards proactive healthcare, not reactive healthcare.

Besides, in the case of the government’s Ayushman Bharat scheme, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the universal health insurance scheme, has received considerable attention and resources than the health and wellness centres (HWCs) component. This asymmetry needs to be suitably addressed for the growth of healthcare in the future.

High out-of-pocket expenditure remains a stress factor

While public hospitals offer free health services, these facilities are understaffed, poorly equipped, and located mainly in urban areas. It is a known fact that accessible and affordable healthcare in the public sector can considerably reduce the rise in dependence on private institutions. However, governmental facilities leave no alternatives but to access private institutions and incurring high out-of-pocket expenses in healthcare. Most health services are, therefore, provided by private facilities, and 65 per cent of medical expenses in India are paid out of pocket by patients.

A possible solution to address the issue could be to increase the adoption of health insurance. In this regard, the government and private institutions both need to work together. Adoption of digital insurance processing solutions integrated with the healthcare ecosystem for faster turnaround time for insurance processes will also motivate adoption of health insurance.

Less emphasis on Preventive Care

Like insurance, very little to no focus is given to preventive care in India. Preventive care can actually solve a lot of problems for the patient in terms of misery or financial losses. Lack of awareness is a key reason for the current situation. Proper preventive care can help save huge costs for the patient and reduce the burden on the limited healthcare infra system in the country.

In current times of COVID19, one can see a lot of people breaking lockdown rules and not even following the basics of masks and gloves, despite government running campaigns on preventive care for the virus. The general health advisory may not solve the root cause of the illness and may invariably add up to an escalated cost owing to a prolonged treatment process. The need of the hour is to increase the number of specialised medical experts in the country.

Delay in Diagnosis of Illnesses

As goes an old saying, A stitch in time saves nine, post preventive care, the next step is the diagnosis, if done in time can not only help save cost but also lives in some cases. We often hear of cases being diagnosed only at an advanced stage when very little can be done to save the life. The importance of diagnosis is mostly doubted in India.

No Support for Medical Research

Indian players so far continue to be the followers of global trends and contract manufacturers for MNCs at best, while not much impetus is given to R&D, and cutting-edge technology-led new initiatives. Even when it comes to updating the knowledge of new discoveries in the medical field we are far behind. The medical professionals and pharmaceutical companies should keep themselves updated with knowledge of the latest development in the field of the medical sector that will help them to cater the right services to patients with minimum risk. Having state of the art technology requires huge cost. On the other hand, adopting ‘Made in India’ medical devices which are more reliable and economical will help the administrator to balance the fund profile and save a huge amount of the capital which can be used for providing basic facilities to the patients.

Cost & Transparency

The most important aspect and perhaps which touches most of us is that the cost and transparency of treatment. In an ideal situation it should be like a menu card in a restaurant; where ingredients and rates of services are mentioned in advance, so the patient does not get surprised on receipt of bills. Besides patients can decide whether to take those services or not; looking at his/her budget. Besides these, patients can also decide whether to opt for those services or not; keeping their budget in mind.

Serving the Nation by providing services empathetically, without any vested interest can give great joy which is a reward in itself for the medical professional and pharmaceutical companies. What primarily ails the healthcare system is that there has been a general lack of focus on the vertical from the government. For years now, knee-jerk reaction work is being witnessed towards the improvement of quality of service.

National Health Policy 2017

Previous Policies

• • The National Health Policy of 1983 and
  • The National Health Policy of 2002

They have served well in guiding the approach for the health sector in the Five-Year Plans. The current context has however changed in four major ways.

• The health priorities are changing. Although maternal and child mortality have rapidly declined, there is growing burden on account of non-communicable diseases and some infectious diseases.
• The emergence of a robust health care industry estimated to be growing at double digit.
• The growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty.
• A rising economic growth enables enhanced fiscal capacity. Therefore, a new health policy responsive to these contextual changes is required.

The National Health Policy, 2017 (NHP, 2017) seeks to reach everyone in a comprehensive integrated way to move towards wellness.  It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost.

Specific Quantitative Goals and Objectives

Health Status and Programme Impact

1. Life Expectancy and healthy life
   • Increase Life Expectancy at birth from 67.5 to 70 by 2025.
   • Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden of disease and its trends by major categories by 2022.
   • Reduction of TFR to 2.1 at national and sub-national level by 2025.
2. Mortality by Age and/ or cause
   • Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
   • Reduce infant mortality rate to 28 by 2019.
   • Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
3. Reduction of disease prevalence/ incidence
   • Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i.e, – 90% of all people living with HIV know their HIV status, – 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
   • Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017.
   • To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025.
   • To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from current levels.
   • To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.

Health Systems Performance

1. Coverage of Health Services
   • Increase utilization of public health facilities by 50% from current levels by 2025.
   • Antenatal care coverage to be sustained above 90% and skilled attendance at birth above 90% by 2025.
   • More than 90% of the newborn are fully immunized by one year of age by 2025.
   • Meet need of family planning above 90% at national and sub national level by 2025.
   • 80% of known hypertensive and diabetic individuals at household level maintain “controlled disease status” by 2025.

1. Cross Sectoral goals related to health
   • Relative reduction in prevalence of current tobacco use by 15% by 2020 and 30% by 2025.
   • Reduction of 40% in prevalence of stunting of under-five children by 2025.
   • Access to safe water and sanitation to all by 2020 (Swachh Bharat Mission).
   • Reduction of occupational injury by half from current levels of 334 per lakh agricultural workers by 2020.
   • National/ State level tracking of selected health behaviour.

Health Systems strengthening

Health finance

• • Increase health expenditure by Government as a percentage of GDP from the existing 1.1 5 % to 2.5 % by 2025.
  • Increase State sector health spending to > 8% of their budget by 2020.
  • Decrease in proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.

Health Infrastructure and Human Resource

• • Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in high priority districts by 2020.
  • Increase community health volunteers to population ratio as per IPHS norm, in high priority districts by 2025.
  • Establish primary and secondary care facility as per norm s in high priority districts (population as well as time to reach norms) by 2025.

Health Management Information

• • Ensure district – level electronic database of information on health system components by 2020.
  • Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
  • Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.

Policy thrust

1. Ensuring Adequate Investment – The policy proposes a potentially achievable target of raising public health expenditure to 2.5% of the GDP in a time bound manner.
2. Preventive and Promotive Health – The policy identifies coordinated action on seven priority areas for improving the environment for health:
   • The Swachh Bharat Abhiyan
   • Balanced, healthy diets and regular exercises.
   • Addressing tobacco, alcohol and substance abuse
   • Yatri Suraksha – preventing deaths due to rail an d road traffic accidents
   • Nirbhaya Nari – action against gender violence
   • Reduced stress and improved safety in the work place
   • Reducing indoor and outdoor air pollution
3. Organization of Public Health Care Delivery – The policy proposes seven key policy shifts in organizing health care services.

It has several challenges such as lack of infrastructure and amalgamation of various streams of the healthcare sector, which will have to be addressed if it has to be a success story.

• First, challenges of inadequate facilities, infrastructure, coverage, access and quality continue to plague the health system. Over 95% of facilities function with less than five workers, and only 195 hospitals in the entire nation operate with quality certifications. Essential diagnostics, such as mammograms have scant coverage of only 1%
• While one would expect private sector care to have higher quality, there is increasing evidence suggesting poor quality. Problems with the public and private health setup are largely the same—gulf of difference between the reported and actual diagnostic and treatment facilities, the tendency of over-prescribing and subjecting patients to unnecessary interventions, lack of efficient monitoring mechanisms, and poor implementation of regulatory controls
• limited use of the health management information system as a proactive management tool in government health programmes. There is also inadequate linkage between research institutions and the implementation wing. The HIV/AIDS programme seems to be losing steam due to shortage of resources and dwindling political commitment,
• An area of major concern is environmental degradation, with the pollution levels in most major cities reaching alarming proportions, even as India wakes up to a major health threat. “Almost half of our urban population does not have basic civic amenities. In the name of industrialization and development of our backward areas, we are polluting the limited sources of safe drinking water of local communities. The indiscriminate use of pesticides is a cause for serious long-term worry. Public places and even the holiest rivers of this country are fast turning into garbage dumps,