Health Policies in India: A Review

K. Srinivasan

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Topics Covered
Policies before Independence Policies after independence in 1947; 1983,2002,2005 Cumulative Impacts of programmes Inter state variations in selected demographic measures -2008 Slow down in progress in RCH in the post 1998 period with pre 1998 period Economic Liberalization and health expenditures Sharp Increases in private expenditures on health Summary and Conclusions
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Policies before Independence

There were no health policies as such for colonial India In most provinces there were sanitary commissioners or directors of public health responsible for sanitation and control of small pox, cholera and plague; in some areas guinea worm control and malaria control Death rates were high close to 30 to 40 per 1000 population ; very high during major epidemics. In 1943 , for the first time ,a committee headed by Sir John Bhore was appointed to study the existing health conditions and make recommendations to prevent communicable diseases , promote health and provide basic health care . It submitted its report in 1946 , called the Bhore Committee report, and the major recommendations therein still form the basis of the Indian public health system

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Basic Recommendations of the Bhore Committee

The Bhore Committee, concentrated on preventive medicine and tried to link health with social justice. It gave some pragmatic directions recommending population based national net work of maternity sub-centers (SC- one for 20,000 population), a primary health center ( PHC- one for one lakh population) and a secondary center , also called the referral center ( SHCone for each taluka or teshil) and a specialized hospital with teaching facilities at the district level The minimum required staff at each level and their expected functions were also recommended in the report The main objective of this population based health infrastructure is to provided basic maternal care, family planning services, immunizations against small pox, cholera and plague , vector control for prevention of malaria and treatment of tuberculosis. It also recommended national level planning and execution of many public health programs.
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Policies after Independence in 1947

The recommendations of the Bhore Committee were accepted for implementation A Committee was set up by the Director General of Health Services to set up the vast number of sub-centers , primary health centers ( PHC) and taluka level hospitals. In 1950 according to the constitution of India , in the allocation of responsibilities between the center and the state, health became a state responsibility. In the initial setting up of the SC, OHC s , UNICEF provided assistance to the state and the central governments in the design and construction of buildings, providing vehicles to PHCs and drugs and equipments.
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Programmes undertaken
In the first two five year plans 1951-1961 , it was essentially devoted to the setting up of the Scs and PHCs and the setting up of the vast net work of ANM and LHV training centers throughout the country. The focus of services was in providing basic ante natal care , home delivery by ANMs or the trained birth attendants( Dais) and vaccinations against small pox , cholera , sanitation programmes and spraying with DDT for malaria control. There were a number of national programmes, NSEP,NMEP etc., that were relatively more successful than state run programmes. There was also great emphasis on providing contraceptive services , initially providing diaphragm and jelly for women, condom for men as temporary methods for spacing and vasectomy for men as permanent method. The crude death rates began to drop as a consequence and expectations of life began to increase.
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Bhore Committee was followed up by many other Committees set up by GOI

The Mudaliar Committee that gave its report in 1962 concentrated on medical education and development of training infrastructure for static medical units. The Shrivastav Committee that gave its report in 1975 urged the training of a cadre of health assistants to serve as links between qualified medical practitioners and multipurpose workers (e.g. school teachers, post masters, gram-sevaks, etc.). There were other committees such as the Kartar Singh committee and Jungalwalla Committee to look into the specific issues of service delivery at different levels.

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Right to Health global movements

Russia was the first country to give its citizens a constitutional right to all health services. The French Constitution of 1946 guarantees to all... protection of health. In 1965-66, the Social Legislation in the United States declared health a human right. The 89th US Congress changed the concept of health maintenance from an individual to a social responsibility by enacting Medicare and Medicaid, and Comprehensive Health Planning from the womb to the tomb'. Most nations are continuously planning newer strategies to put the Right to Health and Medical Service into practical use. The declaration by the International Conference on Primary health Care held in Alma Ata ( USSR) in 1978 declared the goal of global health programs should be Health for All by 2000

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Alma Ata discussions and declarations were a land mark in global health
For the first time Primary health care as define: Reflect and evolve from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience; Address the main health problems in the community, providing promotive, preventive,curative and rehabilitative services accordingly; Include at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and Injuries; and provision of essential drugs;
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Alma Ata ( Contd.)

Involve, in addition to the health sector, all related sectors and aspects of national an Community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors; Require and promote maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate; Should be sustained by integrated, functional and mutually supportive referral systems, Leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need; Relies, at local and referral levels, on health workers, including physicians, nurses, Midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the 6/13/2011 10 community.

Alma Ata ( Contd)

8. All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's resources and to use available external resources rationally. 9 All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world. 10 An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, dtente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.
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Alma Ata ( Contd)

The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration. The Alma Ata declaration appeared to be a mere global wish list

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National Health Policy 1983

The NHP, 1983, was the first attempt to synthesise recommendations of three important earlier committees, the Bhore Committee of 1946 (Government of India, 1946), the Mudaliar Committee of 1962 (Government of India, 1962), and the Shrivastav Committee of 1975 (Government of India, 1975, 1976) and the Alma Ata declaration of global demand of Health for All by 2000\. It was largely dictated by global slogans and the field realities in India. All targets were set to be achieved by 2000 , as was in Alma Ata declaration , IMR of 60 by 2000 , MMR of 200 by 2000 etc. It also reiterated the resolution of taking health services to the doorstep of the people and ensuring fuller cooperation of the community, it failed to even declare health care as a fundamental right of the people and quieted the WHO preamble of 1948 that states, The enjoyment of the highest attainable standard of health is one of the fundamental Rights of every human being without distinction of race, religion, political belief, economic or social condition None of the health impact goals set in NHP 1983 were achieved by 2000..
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National Health Policy 2002 and NRHM 2005

The second major policy endeavor is National Health Policy 2002 (NHP 2002) and it closely followed on the heels of the National Population Policy 2000 ( NPP 2000) Both policies grew in the context of liberalization and globalization The concept of Health for All and Health is a Fundamental Human Right that was the corner stone of the Soviet Health Policy was given a go bye. After the collapse of the Soviet Union the health programs were also gradually privatized. However ambitious health goals were set in NHP 2002. NHP 2002 was followed by a massive National Rural Health Mission launched by the Prime Minister in 2005
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National Health Policy - 2002

Goals to be achieved by 2015
Eradicate Polio and Yaws -----------------------------------------------2005 Eliminate Leprosy ---------------------------------------------------------2005 Eliminate Kala Azar -------------------------------------------------------2010 Eliminate Lymphatic Filariasis -----------------------------------------2015 Achieve Zero level growth of HIV/AIDS------------------------------2007 Reduce morality by 50% on account of TB Malaria and other vector and water borne diseases ------------------------2010 Establish an integrated system of surveillance National Health Accounts and Health Statistics -------------------2005 Increase health expenditure by Government as a % of GDP from the existing 0.9% to 2.0% --------------------------2010* Increase share of central grants to constitute at least 25% of total health spending --------------------------------2010 Increase state sector health spending from 5.5% to 7% of the Budget ---------------------------------------------2005 Further increase to 8% of the Budget -------------------------------2010

Cumulative Impacts of programmes - data on selected indicators at national level for recent years ( demographic)
POPULATION AND VITAL STATISTICS* Total population (in thousands) 1210 million Population density (persons per sq km) 382 per sq. km Sex ratio (females per 1000 males) 940 females per 1000 males Population under 15 years estimated 31 (%) in 2011 Population 60 years and above estimated 8 (%) in 2011 Crude birth rate (per 1000 population) 22.8 in 2008 Crude death rate (per 1000 population) 7.4 in 2008 Natural (population) growth rate (%) 1.54 in 2008 and 1.64 during 2001-11 Total fertility rate (per woman) estimate 2.7 in 2005-06

*Source: Census 2011

Health Inputs Facilities and Personnel

B. Facilities Number of hospital beds 683545 in 2006 Hospital beds per 10,000 population 9 in 2006 Number of health centres: Sub Centre 137371 in 2001 Primary Health Centres 22842 in 2001 Community Health Centres 3043 in 2001 C. Human resources Physicians per 10,000 population 7 in 2005 Nurses per 10,000 population: Professional nurses 7.85 in 2004 D. Budgetary resources Total Expenditure on Health (THE) as % of GDP 4.8 in 2003 Public Expenditure on Health (PHE) as % of Total Expenditure on Health (THE) ---25 in 2003 Private Expenditure on Health (PvtHE) as % of Total Expenditure on Health (THE) was 75 in 2003
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Impacts --Continued
E. Health Outcomes Only 51% of Pregnant women received at least three antenatal checkups during pregnancy in 2005-06 Only 48 % of deliveries were attended by trained personnel in 200506 Contraceptive prevalence rate was 56.3 % in 2005-06 Only 44% of Infants reach first birthday fully immunized against diphtheria, tetanus, and whooping cough in 2005-06 70% of Infants reach their first birthday fully immunized against poliomyelitis in 2005-06 56% of infants reach their first birthday fully immunized against measles in 2005 73% of Infants reach their first birthday fully immunized against tuberculosis in 2005 71% of Women have been immunized with tetanus toxoid (TT) during pregnancy 71 in 2005 85% of Population had access to improved water source in 2001 Only 52% of Population had access to improved sanitation in 2001
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AIDS control
As per latest data made available by National AIDS Control Organization, the India HIV estimates 2008-09 highlight an overall reduction in adult HIV prevalence and HIV incidence (new infections) in India. Adult HIV prevalence at national level has declined from 0.41% in 2000 to 0.31% in 2009. The estimated number of new annual HIV infections has declined by more than 50% over the past decade.

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Leprosy and TB
Leprosy Prevalence Rate has been further reduced to 0.71/10,000 in March 2010. 32 State/UTs have achieved elimination by March 2010, leaving only Bihar, Chhattisgarh and Dadra & Nagar Haveli. Similar progress of elimination has also been in 81% of districts and 77% of Block PHC in the country. TB mortality in the country has reduced from over 42/lakh population in 1990 to 23/lakh population in 2009 as per the WHO global report 2010. Prevalence of TB in the country has reduced from 338/lakh population in 1990 to 249/lakh population by the year 2009 as per the WHO global TB report, 2010.
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Maternal Mortality Rates

India has witnessed an increase in institution delivery recently, from 25.4 per cent in 2001 to 34.9 per cent in 2006. The MMR per 100,000 live births has also declined significantly from 407 in 19971998 to 301 in 2001-2003 and to 254 during 2004-2006 . A systematic analysis using data from National Family Health Surveys, District Level Household Surveys and Sample Registration System has also revealed a significant decline in MMR from 677 in 1980 to 254 in 2008. There is a strong association between increase in percentage of institutional deliveries and reduction in MMR values across the country even in less developed states as Bihar and Chattisgarh

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Inter state variations in selected demographic measures for the four southern states and four less developed states-2008

State Andhra Pradesh Karnataka Kerala Tamil Nadu Uttar Pradesh Bihar Madhya Pradesh Rajasthan India

Birth Rate 18.4 18.8 14.6 16 29.1 28.9 28

Death Rate 7.5 7.4 6.6 7.4 8.4 7.3 8.6 6.8

Infant Mortality Rate 52 45 12 31 67 56 70 63 53

Life expectancy ( female) ( 2006-10) 69.4 71.1 76.8 70.6 64.4 66.7 63.3 69.2 68.1

22.8

7.4

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23

24

25

26

M ah ar as h T am tra il N a W es du tB en ga l Pu nj K a ar b na ta k H a ar ya na

30

30

In di a G uj ar at

Time Lag between Kerala and Other States in Infant Mortality Rate in 2008 (in years)

31

31

32

35

37

37

38

B i A h ar nd hr a Pr . A ss am R aj as U tt th a a n M rP ad r a hy de sh a Pr ad es h O ri ss a

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Slow down in progress in RCH in the post 1998 period with pre 1998 period
We compared very carefully the pace of change between 1992-93,1998-99 and 2005-06 in selected health indicators using NFHS-1,2 and 3 data sets At the state level for 22 states for which information was available in all three rounds of NFHS surveys, 1992-93,1998-99 and 2005-06 for 29 impact indicators. The indicators were grouped into three major categories: A Marriage and fertility; B: Family Planning and C: Maternal and Child Health. At the all India level the number of indicators covered in these three categories were 7, 10 and 12 respectively. It can be seen from the enclosed table that in most of the states the pace of improvement in the post-1998 period is less than in the earlier period; with the median values of 50 percent in the first category, 60 percent in the second category and 65 percent in the third category. RCH program implemented after 1998 has not been particularly successful on a number of RCH indicators. If we adjust the effects for per capita expenditures spent on the RCH program in pre and post-RCH period, the differentials get accentuated since the expenditure on RCH after 1998 has almost doubled on a per capita basis compared to 1992 to 1997 period.
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State-wise total number of cases and percentages indicating pre 1998 changes greater than the post 1998 period in the three selected groups of Indicators
Marriage and Fertility A(7) India AP AR AS DE GJ GO HP HR KA KE MG MH MN MZ NA OR PUN RJ TN TR UP WB Median 4 3 3 4 2 1 2 5 7 6 4 1 3 2 1 2 3 6 2 2 4 3 7 Family Planning B(10) 7 5 6 5 5 7 3 5 6 6 2 2 4 3 6 5 6 8 5 0 3 2 7 5 Maternal and Child Health C(12) 10 9 10 4 11 10 9 9 9 9 10 1 7 8 11 10 8 9 4 11 9 7 6 9 21 17 19 13 18 18 14 19 22 21 16 4 14 13 18 17 17 23 11 13 16 12 20 17 57 43 75 57 29 14 29 71 100 86 57 25 43 50 25 50 43 86 29 29 100 43 100 50.0 70 50 60 50 50 70 30 50 60 60 20 20 40 30 60 50 60 80 50 0 30 20 70 50.0 83 75 83 33 92 83 75 75 75 75 83 8 58 67 92 83 67 75 33 92 75 58 50 75.0 =S/29*100 72.4 58.6 65.5 44.8 62.1 62.1 48.3 65.5 75.9 72.4 55.2 15.4 48.3 50.0 69.2 65.4 58.6 79.3 37.9 44.8 61.5 41.4 69.0 61.5 S=A+B+C =As/7*100 =Bs/10*100 =Cs/12*100 Overall

Percentage of indicators where there was a slow down of progress in the post 1998 period compared to pre 1998 period
90 80 70 60 50

59 55 45 45 48 48 50

59

62

62

62

65

66

66

69

69

72

72

76

79

41
40 30 20 10 0 MG RJ UP

38

15

AS

TN

GO

MH

MN

KE

AP

OR

TR

DE

GJ

NA

AR

HP

WB

MZ

IND

KA

HR

PUN

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Percentage of RCH indicators where improvements slowed down after 1998

90 80 70 60 50

59 55 45 45 48 48 50

59

62

62

62

65

66

66

69

69

72

72

76

79

41
40 30 20 10 0 MG RJ UP

38

15

AS

TN

GO

MH

MN

KE

AP

OR

TR

DE

GJ

NA

AR

HP

WB

MZ

IND

KA

HR

PUN

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Economic Liberalization and health expenditures

Economic liberalization since the late 1980s has encouraged private industries in the health sector by opening up of hospitals, nursing homes, laboratories etc These increased number of private health facilities along with lure of better quality of services advertised through the media has attracted a large number of patients to the private sector. This escalating demand has pushed private health care expenditure sky rocketing. In this context the following tables provide how liberalization had impacted on the use of health care utilization between public and private sectors and how poorer section of society has been affected. First ,we have used the data from NFHS and then from NSS
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Findings from analytical studies on secular trends in mortality ( Nandita Sakia, F Ram et al.,)
Analysis of changes in life expectancy between the exact ages 0 and 60 years shows that after a spectacular progress during the 1970s and the 1980s, improvements in longevity slowed down in the 1990s and 2000s. Gini coefficient and dispersion measure of mortality confirm the convergence of mortality across the regions in India between 1971-75 and 2000-2004. In spite of this trend, a substantial difference between higher longevity in the south and lower longevity in the north was noteworthy in 2001-2004. Age-decomposition of life expectancy by age group 0-14 and 15-59 suggests that the steep longevity increase in the 1970s-80s was largely driven by mortality reduction of children under age 15. In the 1990s and the early 2000s, the contribution of both young and adult age groups into the longevity increase has diminished. India faces difficulties in making progress in further reduction of infant death to the minimum levels and also in fight with chronic and man-made diseases at older ages. 6/13/2011 30

Temporary life expectancy between exact ages 0 and 60 for Indian states in 2000-2004

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Temporary life expectancy between exact ages 0 and 60 for Indian states in 2000-2004

Sharp changes in the use of private health facilities and expenditures on health Percentage of households by reported sources of health care by major states: NFHS Data
NFHS-2-1998-99 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Public 14.76 74.68 9.13 27.67 16.06 58.81 33.80 37.90 34.04 21.34 83.91 13.81 62.99 37.89 11.43 24.19 28.66 Private 81.75 24.87 88.72 69.84 83.84 41.07 65.45 60.52 63.13 77.73 15.24 85.85 36.11 61.15 87.87 60.31 68.60 Others 3.49 0.45 2.15 2.48 0.10 0.11 0.75 1.58 2.83 0.92 0.85 0.33 0.90 0.96 0.70 15.51 2.74 Public 25.75 65.17 6.74 27.46 27.74 82.73 35.97 49.96 37.39 29.66 76.04 19.25 70.18 52.99 15.30 28.80 34.04 NFHS-3-2004-5 Private 73.74 34.46 92.90 69.81 72.17 16.98 63.03 49.05 61.93 69.63 22.81 80.07 29.57 46.64 84.23 70.53 65.20 Others 0.51 0.37 0.36 2.73 0.10 0.29 1.00 0.99 0.67 0.71 1.15 0.68 0.25 0.38 0.47 0.67 0.76

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Major findings from the previous table

According to NFHS data between 1998-99 and 2004-05 reported utilization of private health facilities have marginally come down from 69% to 65% Reported utilization of private health facilities in 2004-05 is lowest Himachal Pradesh at 17% i (down from 41%in 1998-99),Orissa at 23% ( an increase from 15%), Rajasthan at 30%( down from 36%) and highest in Bihar at 93% ( increase from 89%) In Tamil Nadu the percentage use of private facilities has declined from 61% to 47%. In Marxist ruled state of West Bengal the use of private health facilities is high at 71% in 2004-05 ( increased from 69% in 1998-99) Thus the NFHS- 2 and 3 data give a slightly rosy picture of the increased use of public health facilities between 1998-99 and 2004-05 across many states.
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Percent of households using private health care by standard of living and States
NFHS-II- 1998-99 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Low 76.72 24.22 89.38 51.69 83.53 41.23 53.89 42.31 59.75 68.73 12.91 81 32.11 45.39 90.17 51.83 62.46 Medium 83.79 21.42 89.33 68.98 81.43 39.42 66.02 57.89 65.04 78.67 15.91 84.57 36.57 66.5 87.62 62.92 69.32 High 89.76 42.03 81.75 87.26 86.77 45.36 82.59 77.4 65.26 88.9 28.05 87.44 39.47 91.77 83.77 81.8 78.81 Total 83.42 29.22 86.82 69.31 83.91 42.00 67.50 59.20 63.35 78.77 18.96 84.34 36.05 67.89 87.19 65.52 70.20 Low 62.73 27.81 93.2 50.93 70.35 8.05 46.16 16.67 56.84 51.98 20.85 76.72 24.2 26.09 84.22 64.92 58.5 NFHS-III- 2004-05 Medium 72.58 29.4 93.27 60.92 71.26 17.05 59.94 25.78 62.38 63.7 20.74 79.93 26.61 39.41 85.11 68.45 62.47 High 83.69 49.46 91.54 78.71 73.04 17.91 76.66 59.96 68.56 80.09 31.25 80.38 36.85 70.21 83.39 79.31 72.19 Total 73.00 35.56 92.67 63.52 71.55 14.34 60.92 34.14 62.59 65.26 24.28 79.01 29.22 45.24 84.24 70.89 64.39

Findings from the earlier table

Analyzed by standard of living, the use of private health facilities among the most poor is lower than in other economic groups both in 1998 and 2004 but still stands high at 59% in 2004-05 ( a slight decline from 62% during 1998-99) In Tamil Nadu the percentage of poor group using private healthy facilities has declined substantially from 45% to 26%. The highest percent use of the private health facilities by the poor population group is in Bihar ( 93%) and Uttar Pradesh ( 84%) and the lowest is in Himachal Pradesh ( 8%) , Kerala ( 17%) , Rajasthan 24% and Tamil Nadu , 26%. This indicates the more extensive and better quality health and medical services offered in the public health sector in the states mentioned above. In many of the states there is a rise in the percentage of the poor households using private health facilities but in Kerala there is significant decline from 42% in 1998-99 to 17% in 2004-05. However, in all the states there is a systematic rise in the use of private health facilities with the rise in the economic status of the families from the low to the middle and to the high categories ; in 2004-05 it was 58% among the poor, 62% among the middle and 72% among the high.
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Percentage of people seeking out patient care in private hospital, by monthly percapita household consumption expenditure categories( MPCE): NSS DATA
52nd Round, 1995-96 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Low 70.29 56.76 89.35 58.97 100.00 75.00 78.85 43.48 77.78 85.49 38.95 96.36 55.17 75.00 93.40 81.20 76.03 Medium 83.06 60.00 88.46 77.55 82.50 56.34 81.25 63.96 76.25 85.71 37.25 93.10 37.21 69.57 94.36 83.33 75.95 High 92.11 65.38 79.55 76.87 86.36 60.00 77.08 80.65 68.25 91.16 26.32 91.56 45.90 74.40 88.70 83.33 76.10 Total 78.93 60.20 87.38 72.76 86.02 60.45 79.05 70.26 74.55 87.33 36.97 92.52 45.11 72.85 92.54 82.46 76.02 60th Round, 2004-05 Low 70.29 54.61 91.40 59.13 82.14 59.77 64.78 54.84 69.1 76.31 34.61 87.50 46.74 54.68 84.70 68.02 67.53 Medium 74.94 66.89 89.43 74.59 77.61 53.30 70.08 65.16 69.2 85.53 38.51 80.15 49.79 70.32 85.91 77.68 71.72 High 85.03 77.78 85.22 86.27 84.77 48.16 84.48 77.40 70.0 89.10 57.27 80.97 47.89 82.47 82.53 84.41 77.84 Total 77.18 64.11 90.15 77.58 81.90 54.26 73.46 68.77 69.4 85.34 39.14 81.34 48.28 70.95 84.66 77.01 72.66

Findings from the previous table

The percentage of patients seeking outpatient care in private hospitals or doctors in Low economic starta is 68% in 2004-05 and has declined from 76% in 1995-96. Such a decline is corroborated by the NFHS data. This is a welcome sign indicating that there is an increased utilization of public health facilities during this period, by the poor, as observed earlier from an analysis of NFHS data sets. In Tamil Nadu the percentage of poor patients seeking outpatient care in private hospitals or doctors declined from75 to 55% On the other hand there is an increase in this percent and is very high in Bihar ( 91%), Punjab ( 88%) and Uttar Pradesh ( 85%) but quite low in Orissa (35) and Rajasthan ( 47). There is a systematic increase in the percentage out patients using private medical institutions with the rise in the economic status of the households in all the states excepting Himachal Pradesh, where there is a declining use by the rich compared o the poor.
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Percentage of people seeking in-patient care in private hospital by MPCE categories

52nd Round, 1995-96 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Low 58.27 23.21 62.04 57.14 66.67 11.11 33.33 48.19 38.10 49.51 10.67 80.00 18.18 36.23 53.47 9.03 36.38 Medium 73.23 3.64 72.46 56.90 71.43 10.71 60.94 51.92 42.86 69.15 15.79 60.00 25.84 60.50 50.00 33.77 44.90 High 87.88 40.00 83.05 71.83 71.43 20.75 66.07 79.65 46.55 82.54 13.64 69.64 29.27 75.00 56.35 36.96 57.07 Total 73.13 22.28 72.52 61.96 69.84 14.19 53.45 59.92 42.50 67.07 13.36 69.88 24.43 57.25 53.27 26.58 46.12 60th Round, 2004-05 Low 63.37 18.41 84.51 57.57 77.22 17.14 56.07 53.68 40.49 58.63 18.19 66.67 38.27 42.38 65.57 15.81 47.76 Medium 68.67 22.68 82.77 70.42 66.23 22.39 61.64 60.54 55.44 72.64 27.11 67.43 40.19 54.35 71.68 25.92 51.92 High 74.59 39.37 81.03 76.72 72.9 24.32 79.66 74.61 65.31 80.05 31.68 75.42 46.86 77.61 73.4 45.13 62.24 Total 68.85 25.51 83.67 70.31 71.15 22.04 65.5 65.21 50.26 72.02 22.01 72.42 41.8 60.12 69.49 27.97 54.05

Findings from the earlier table

The percent of household seeking in-patient care in private hospitals increased sharply from 36 to 48 during 1995 to 2004 even among the poor. Even in Tamil Nadu it increased from 36 to 42% among the poor Between 1995 and 2004 there is a significant rise in the percentage of inpatients in private medical care in most of the states; the maximum increase in percentage points is noticed Karnataka ( 33 to 56) Rajasthan from (18 to 38). Only in Punjab and Assam there is a decline in private use from 80 to 67 and from 23 to 18 during this period.

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Out-patient Cost by Sources of Treatment and States

52nd Round, 1995-96 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Public 129 124 211 112 161 136 85 96 221 79 130 174 177 58 307 78 148 Private 183 139 221 139 195 94 150 107 255 130 78 160 514 140 205 144 174 60th Round, 2004-05 Public 100 148 299 132 196 215 99 89 194 114 179 287 233 27 233 156 169 Private 190 186 241 184 198 209 208 148 205 187 163 167 217 184 207 187 191

Percapita out patient expenditure incurred in private health facilities by MPCE categories.
52nd Round, 1995-96 Low Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Total 94 96 139 28 83 14 75 75 110 41 85 8 109 48 234 88 98 Medium 121 127 206 149 148 112 47 101 391 82 146 45 137 79 227 66 144 High 289 175 340 131 185 158 127 102 118 125 300 221 222 32 507 76 198 Low 146 133 210 161 129 141 127 101 136 136 118 148 165 143 156 113 148 60th Round, 2004-05 Medium 176 171 254 150 131 187 167 125 191 152 231 152 216 138 210 137 170 High 230 289 380 209 254 349 296 177 365 226 202 176 255 237 300 280 241

Findings from the earlier table

The percapita outpatient expenditure incurred in private health facilities in one year in the low MPCE category increased from Rs 98 in 1995 to Rs148 in 2005, almost 50% rise. This increase is maximum in Tamil Nadu , from Rs 48 to Rs 143 and surprisingly the highest in 2004 in Bihar ( Rs 210) , UP ( Rs 156) and Gujarat ( Rs 161) . The amount spent percapita on outpatient services from private hospitals in all MPCE categories increased in most of the states during 1995 to 2004 excepting in UP where there is surprisingly a decline.

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Inpatient Cost by Source of Treatment and States

52nd Round, 1995-96 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Public 1546 1367 2390 1426 1752 1509 1016 955 1780 2801 1369 2540 1738 571 2793 737 1766 Private 1937 2731 3106 3136 3451 2352 2376 2810 2222 2379 1564 4360 2445 2650 3829 2559 2745 60th Round, 2004-05 Public 1471 1261 3007 1806 5793 2899 870 1813 1723 1499 1678 4553 2602 783 3095 1568 1807 Private 3369 4938 3111 3554 4304 5324 3508 3137 3854 4341 3886 7397 4395 5037 3999 5490 4131

Findings from the earlier table

The inpatient expenditure in public health facilities increased only marginally between 1995 and 2004 in the country as whole from Rs 1766 to Rs 1807 and in and in private institutions from 2745 to 4131. In Tamil Nadu the increase was from Rs 571 to 783 in pu8blic and from Rs 2650 to 5037 The increase in percapita in patient expenditure per year incurred in private health institutions between 1995 and 2004 was more than Rs 2000 in Assam, HP, Maharashtra, Tamil Nadu and west Bengal. We see the enormous inroads of private hospitals and nursing homes in inpatient care in the above states. There appears to be a ever widening scope of activity of private medical care institutions thro. In-patient services and increasing charges.

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Percapita in-patient health care cost by MPCE categories

52nd Round, 1995-96 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Low 1105 911 1527 979 1269 3202 1676 579 2050 1010 581 2471 1485 1110 1930 1025 1349 Medium 2084 1012 2856 1630 3993 2331 1830 1079 1545 1550 1018 1847 1616 1864 2783 2151 2027 High 2597 3827 5660 4939 3583 2157 3305 4902 3208 3486 7025 5260 3523 4433 6528 4059 4398 60th Round, 2004-05 Low 2132 1994 2225 1781 2495 4277 2514 2029 2169 2627 3269 2603 3940 1864 2939 2576 3272 Medium 2659 7662 4361 2094 3292 3643 2705 2864 4229 3388 4386 4052 4422 3055 3578 3461 3855 High 5175 3876 5383 5184 5286 7357 4888 3684 5794 5750 4862 9320 4710 7471 7666 5722 5355

Findings
The in patient hospital expenditure for the poor increased from Rs 1349 in 1995-96 to Rs 3272 in 2004-05 while for the higher income group it increased from Rs 4398 to Rs 5355 In Tamil Nadu the inpatient hospital expenditure for the poor increased from Rs.1130 to 1864 The increase in percapita inpatient expenditure for the low MPCE group is highest in HP ( Rs. 4277), Rajasthan ( Rs.3940) and Orissa ( Rs. 3269) and lowest in Gujarat ( 1781) and Tamil Nadu ( 1864)
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Proportion of Total Medical Expenditure to Household Expenditure by Expenditure groups and States
NSS 52nd, 1995-96 States Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Low 12.44 9.77 14.05 2.98 4.11 13.87 5.99 4.23 4.93 10.40 10.23 4.68 4.10 5.52 10.08 5.22 7.57 Medium 12.80 19.67 12.37 5.08 17.58 16.80 6.59 8.80 9.33 4.28 13.80 6.70 5.86 6.33 14.02 6.17 7.94 High 10.09 14.76 24.68 9.94 17.13 23.38 7.64 16.41 8.29 4.04 8.30 15.14 14.72 11.34 21.42 5.01 10.63 Total 11.53 15.12 16.54 6.93 15.18 20.25 6.88 11.17 7.50 5.04 10.78 11.36 8.44 8.06 15.45 5.45 9.07 Low 22.03 11.99 20.57 17.52 19.37 30.30 16.64 27.95 22.38 17.33 18.97 24.53 23.46 17.37 25.32 17.01 20.15 60th, 2004-05 Medium 21.06 11.02 19.07 13.59 15.77 22.32 14.12 23.87 16.08 22.17 18.81 20.51 20.46 14.94 23.80 16.40 17.21 High 19.17 11.16 18.03 13.50 19.10 20.73 16.17 18.38 12.10 39.89 12.41 20.55 15.50 21.11 19.53 21.20 15.65 Total 20.33 11.28 19.59 13.96 18.21 22.52 15.66 20.79 14.48 26.51 16.98 20.77 18.73 18.85 22.71 18.97 16.99

Findings
The percentage of expenditure on medical care to total household consumption expenditure has almost doubled in the last decade, increasing from 9 to 17 between 1995-96 and 2004-05. Among the low Income group it has tripled from 8 to 20, in the middle income group from 8 to 17 and in the high from 11 to 17. The poor are spending a higher percentage of their total consumption expenditure ( 20) than the higher economic groups. In Tamil Nadu this proportion increased very sharply from 6 to 17 %and the maximum increase is in Kerala from4 to 28% Generally the poor in the less developed states are spending a higher proportion of the consumption expenditure on health care. It varies from 30 in Himachal Pradesh, and 25 in UP 17 in Tamil Nadu and Karnataka and 12 in Assam

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Number of Medical Practitioners by private and public

2008 State Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Karnataka Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal 34380 20307 73116 45415 50375 640338 73508 Private 49895 15484 33774 39396 1511 Public 4487 2103 3979 3589 1836 NA 5023 6555 5079 3545 6285 7107 6766 6113 84852 Ratio 11.12 7.36 8.49 10.98 0.82 # 14.63 0.00 0.00 9.70 3.23 10.29 6.71 8.24 7.55

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Findings
The ratio of private to public medical officers in the country as a whole is estimated at 7.55 to 1 in 2008 (ranging from a ratio of14.63 in Maharashtra to 0.0 in Orissa In Tamil Nadu it is estimated at 10.3

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Summary and Conclusions

Since independence there has been considerable improvements in the health conditions of Indias population in terms of reductions in mortality and increase in life expectancy. There are however large variations in the improvements across different states with the southern and western states and West Bengal doing much better than other states especially in the so called Hindi belt. On infant mortality and other indicators as MMR the northern states are lagging behind Kerala by almost 25 years. This indicates that any policy at the national level works with varying impacts in different states. The state administration and governance seem to be the crucial deciding factor in the efficiency and effectiveness of any programme. In this respect Tamil Nadu and Kerala have done exceedingly well in strengthening of the public health and medical programmes and running them efficiently

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Summary and Conclusion- contd.

There are also strong secular trends in the impacts of various programmes with the slow down of the pace of declines in mortality and increase in life expectancy after 1995 Liberalization and globalization of health has to some extent adversely impacted on the improvements of health conditions of the poor. There has been a marginal increase he extent of utilization of public health facilities when overall utilization is concerned and this increase is significant in Tamil Nadu However, when hospitalization is concerned there is an increasing preference to use private facilities Hospitalization cost has increased by almost two times in private hospitals in ten years People belonging to poorer section has been paying a higher share of their total consumption expenditure on expenses in private health facilities, especially on in patient care, in the process of liberalization since the cost of such care i.e. increasing rapidly.
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Summary and Suggestions-contd.

There is a need to increase rapidly the number of public health facilities in the country. It is recommended that the existing sub centers may be upgraded in a phased manner into medical and maternity sub centers with a medical officer and an additional ANM. The goal of one doctor per 1000 population should be achieved initially as 1 doctor per 5000 rural population and the remaining in urban areas; at present there is great distortion in the ruralurban break-up with 1 for 10,000 rural population and more than 1 for 1000 in the urban areas. There is a need to set up in every district head quarters institutions on the lines of Voluntary Health Services to provide subsidized specialist care at the district level. Tamil Nadu has a systematic model worth replication in other states In the context of increasing privatization of various services including health services, there is an inherent need for the public health system to compete with private on quality of care. There is a need to publicize through the media high quality public health institutions.
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THANK YOU

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