Prof. K. Srinath Reddy President, Public Health Foundation of India,

1. India’s Health Challenges: Will Universal Health CoverageProvide The Platform For Response? Prof. K. Srinath Reddy President, Public Health Foundation of India, President, World Heart Federation

2. India’s Health Status Lags Behind Economic Growth And Threatens To Slow Down Development 1

3. India is Under performing its Income Group Peers in Health

4. We lose 1,400,000 infants every year, 4000 every day…equivalent to 12 full Jumbo Jets crashing every day. Our children die early, prematurely, and needlessly Infant Mortality Rate Deaths per 1000 live births Out of 100 live births, 5 die before their first birthday – 3 within the first month • Our infant mortality rate is 3X more than China, 4X Thailand or Sri Lanka Believe it or not…we are actually worse than Botswana, Bangladesh & Nepal • It is Lottery of Life - death in childbirth more likely in poorer states - MP (76), 600% higher than Kerala (13) • Most are needless deaths, from preventable causes such as malnutrition, lack of immunisation, diarrhoea, pneumonia and malaria SOURCE: WHO 2012 3

5. And has Lagged Behind

6. On providing basic immunization to our children, we are behind Bangladesh, Nepal, Thailand, Ghana, Pakistan, to name a few 30% of children in India go without DPT coverage, 50% without full immunization DPT immunisation rate % of children covered China 99 Sri Lanka 99 Thailand 99 Brazil 98 Botswana 96 Bangladesh 95 Ghana 94 Myanmar 90 Pakistan 88 Nepal 82 India 72 Nearly 100% children covered in China, Brazil, Sri Lanka or Thailand Source: WDI. WHO 5

7. % underweight below 5 Despite all the progress, 40% children in India are undernourished. A “national shame!” 25% of India’s newborns start life with Low Birth Weight • Of those who survive the first year, 43% are underweight, and 66% anaemic by age of three • Undernourishment severely limits cognitive development and increases vulnerability to heart disease & diabetes Brazil 2 China 7 Thailand 7 Ghana 14 Sri Lanka 22 Sub Saharan Africa 28 Nepal 39 Very few go undernourished in China, Brazil or Thailand. We do worse than sub-Saharan Africa Bangladesh 41 India 43 Source: WDI. WHO 6

8. Our maternal mortality rate is 4X of China and Brazil, 6X of Sri Lanka We only compare favorably with Pakistan, Gabon and Cambodia 60,000 plus mothers die every year. More deaths in a week than in a whole year in Europe A sacrifice to give life – a preventable tragedy 7

9. Incidence and prevalence of infectious diseases remains high TB incidence • 2 million new cases every year • Incidence rate 200-300% more that of China and Brazil. In the range of Afghanistan and Pakistan • Drug resistant TB a major threat Malaria prevalence • 9.7 million cases, with 40,000+ deaths every year (recent ICMR study) • Over 70% of India at risk of malaria infection 8

10. In Chronic (non-communicable) diseases such as diabetes and cardiovascular disorders, we are facing advancing epidemics Diabetes epicenter of the world – 61 million cases in 2011 to rise to 101 million in 2030 Every 8th adult has or is at high-risk. 40-60 working age group most affected India could lose US$ 237 billion (over 2005-2015) to cardiovascular disease and diabetes (WHO) Potentially productive years of life lost due to cardiovascular deaths (36-64 years age group); In millions Underlying risk factors - unhealthy diets, physical inactivity, alcohol consumption and tobacco use 2000 2030 If neglected, this will be a source of continuing productivity loss India China Russia USA 9

11. Quality of Primary Care Scored For: • 24 Hour Availability of Services • Clinical Staff In Position • Training In Past 5 Years • Basic Infrastructure • Equipment • Essential Drugs

12. Public health spend not yet a high priority. Our public expenditure on health is among the lowest in the world More funding needed with right investments such as Primary healthcare | Education and training facilities – medical and public health | Availability of essential drugs to all | Expansion of universal health coverage Need for doubling of public spending on health to at least 2% of GDP by end of 12th Plan Source: WHO database, 2009 11

13. Low Public, High Out of Pocket Health Expenditure

14. Unaffordable and unsustainable healthcare costs 70% of health spend from own pockets on health. Out of pocket (OOP) expenditure amongst highest in the world Over 60 million people thrown below the poverty line every year due to OOP on health Over 40% of hospitalised persons had to borrow money or sell assets to pay for their care 28% of rural residents and 20% of urban residents had no funds for health care Huge social burden on the poor 13

15. High costs of out-patient and medicine costs

16. Number of Doctors – 8.58 lakh (as per IMR) Those available – 6 - 6.5 lakh (75%) (approx) Present Doctor Population Ratio 0.5 per 1000 Target by 2025– 0.8 per 1000 China 1.6 per 1000 USA 2.6 per 1000 UK 2.3 per 1000 Sweden 3.3 per 1000 Current scenario of Doctors • Additional Doctors required – 4 lakh by 2020 • 1.5 lakh in 50,000 PHCs • 0.8 lakh in 12,500 CHCs • 1.1 lakh in 5,642 SDH/DH • 0.5 lakh in 800 MCHs

17. Nurses registered 11.2 lakh Available 9 lakh(Approx) Nurse-Population Ratio 0.4 per 1000 (Nurses +ANM) Vs Doctor Ratio 1.5 : 1 (Desired 3:1) Target by 2025 2.2 : 1 --------------------------------------------------------------------------------------- Brazil 3:1 South Africa 5:1 USA 3:1 UK 5:1 -------------------------------------------------------------------------------------------- Additional Nurses required – 16.2 lakhs by 2020 Current Scenario of Nurses

18. Allied Health Workforce shortfall- National estimate

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

20. Universal Health Coverage is when ALL people receive the quality health services they need without suffering financial hardship

22. National Rural Health Mission (NRHM) HIGHLIGHTS • Decentralized planning and implementation through community participation (through various initiatives such as ASHA, VHSC, SHGs) • Pro poor-based equitable systems • Emphasis on convergence • Flexibility and adequacy of central funding with accountability framework to ensure public action • Judicious mix of dedicated budget lines – untied funds to all public institutions • Provision of incentives for CHWs in hard-to-reach areas • Monitoring progress against standards (such as IPHS) • Targeted interventions to measureable outcomes, reviewed annually through the CRM process SHORTFALLS • Focus on maternal and child health – other primary health care needs not addressed • Quality of care not assured, even for institutional deliveries • Health workforce deficiencies (numbers; skills) affect delivery of services • Impact on out-of-pocket not demonstrated • Continuum of care (10 +20 +30) not developed

23. Rashtriya Swasthya Bima Yojna (RSBY) HIGHLIGHTS • India’s first social-security scheme with a profit motive, involving insurance companies, hospitals, state governments and the Centre • Encourages increased contributions to health and augments financial resources of the State governments • Attempts to address several lacunae regarding enrolment, utilisation levels and fraud control • Mandatory enrolment and technology-based cashless policies address the problem of risk selection and selective rejection of claims by insurers. SHORTFALLS • Low coverage with financial protection available only for hospitalization, and not for out-patient care • Focus on hospital networks rather than primary care services • Difficult to maintain quality of healthcare at accredited hospitals due to induced demand and fraud • Potential for inferior health outcomes and high healthcare cost inflation

24. Key Recommendations of HLEG • Adopt UHC As A National commitment - To Be Initiated in 2012 and Fulfilled By 2022 • Commit 2.5% of GDP As Public Financing for Health During The 12th Plan and suggest MOHFW prepare a road-map for implementation of the UHC • Prioritize Primary Health Care For Financing And Human Resource Development & Deployment • Conduct A Review of Government Funded Insurance Schemes & Propose A Plan for Their Integration Into The UHC Framework • Provide Essential Drugs Free Of Cost • Establish Credible And Effective Regulatory Systems For Administering UHC (Accreditation; Standards; Financing; Drugs; Information Systems; M&E) • Enable Community Participation By Institutionalising Health Councils & Health Assemblies With Government Support • Facilitate focusing future MOHFW agendas on a) Gender -UHC though a gendered lens b) Urban Health c) Social Determinants Of Health (Health Promotion & Protection Trust), while preparing its implementation plan 23

25. Universal Health Coverage By 2022: The Vision • Universal Health Entitlement for every citizen - to a National Health Package (NHP) of essential primary, secondary & tertiary health care services that will be principally funded by the government • Package to be defined periodically by an Expert Group; can have state specific variations

26. Impoverishment due to OOP on Drugs, 2011-12

27. Issues for Debate(Financing) • Tax funded model Vs. Insurance Model • Financing and Impact of Government Funded Insurance Schemes • Role of Private Insurance • Fee for Service Vs. Per Capita Vs. ? • User Fee Exemption : All / Poor only? • Role of Central and State Governments

28. Issues for Debate(Provision) • Role of Public and Private Sectors • ‘Corporatization’ of Public Sector Healthcare Facilities • ‘Managed’ Vs. ‘Integrated’ Care • Continuum of Care : Overcoming Fragmentation • Extent of Integration of Health Programmes (NRHM+NUHM = ? NHM)

29. Options • Options based on coverage (who is covered for what) • All the services to all the population • Some services to all the population • Some services to certain sections of the population • Provision • Within the existing government health services (in an enhanced manner) • Through the private sector (Purchasing, contracting, PPP) • Finance • Enhanced budgetary support based on evidence • Pooling (insurance) –Increasing existing benefit package, coverage under existing schemes (coverage, benefits etc. under RSBY & other schemes) • Incentives (payment for performance), Case based payment, capitation etc. • Based on the options - populations to be covered, services (benefit package) to be provided, method of delivery, estimation regarding financial requirements

30. Options • Options could be a mix of delivery systems providing the services selected from the health package. • Realignment & convergence of programmes and schemes • Development of a essential health package of services into various categories to choose (e.g. primary, secondary, tertiary, etc.) and move towards it systematically & phased manner. • Costing of the benefit package • Broad roadmap on how best to provide the services to the populations and what needs to be strengthened or systems in place and their implications.

31. Human Resources For Health Increase numbers and skills of frontline health workers: • Doubling of ASHAs and ANMs; • Male MPW and Mid Level Health Professional (3 year trainee)/AYUSH at Sub-Centre level; • Expand Staff (esp. nurses) at PHC and CHC; • Nurse-Practitioners for Urban Primary Health Care

32. Human Resources For Health • Establish new medical and nursing colleges in underserved states and districts with linkage to district hospitals; Increase the number of ANM schools • Scale up number and quality of Allied Health Professional training institutions • Establish District Health Knowledge Institutes to coordinate and conduct training of different categories of health workers • Develop Public Health and Health Management Cadres (District, State, National)

33. Registry

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35. “If we don’t create the future, the present extends itself” - Toni Morrison (Song of Solomon)