Health Planning In India

1. Health Planning In India Dr Abhay Nirgude Professor & HoD Dept of Community Medicine

2. National Health Policy-2002 • Objective:- To achieve an acceptable standard of good health amongst the general population of the country. • Approach :- To increase access to decentralized public health system by establishing new infrastructure in the existing institutions. • Primacy:-To preventive and first line curative initiatives at the primary health centre. • Policy :-focus on those diseases which are principally contributing to the disease burden. • Emphasis:- Rational use of drugs within the allopathic system

3. NHP-2002 Goals to be achieved by 2015

4. NHP-2002 Goals to be achieved by 2015

5. National Health Policy 2017 • The broad principles of the Policy are centered on professionalism, integrity and ethics, equity, affordability, universality, patient centered and quality of care, accountability and pluralism. • It aims to achieve universal access to good quality health care services without anyone having to face financial hardship as a consequence.

6. Professionalism, Integrity and Ethics: • The health policy commits itself to the highest professional standards, integrity and ethics to be maintained in the entire system of health care delivery in the country, supported by a credible, transparent and responsible regulatory environment.

7. Equity: • Reducing inequity would mean affirmative action to reach the poorest. It would mean minimizing disparity on account of gender, poverty, caste, disability, other forms of social exclusion and geographical barriers. It would imply greater investments and financial protection for the poor who suffer the largest burden of disease.

8. Affordability: • As costs of care increases, affordability, as distinct from equity, requires emphasis. Catastrophic household health care expenditures defined as health expenditure exceeding 10% of its total monthly consumption expenditure or 40% of its monthly non-food consumption expenditure, are unacceptable.

9. Universality: • Prevention of exclusions on social, economic or on grounds of current health status. In this backdrop, systems and services are envisaged to be designed to cater to the entire population- including special groups.

10. Patient Centered & Quality of Care: • Gender sensitive, effective, safe, and convenient healthcare services to be provided with dignity and confidentiality. There is need to evolve and disseminate standards and guidelines for all levels of facilities and a system to ensure that the quality of healthcare is not compromised.

11. Accountability: • Financial and performance accountability, transparency in decision making, and elimination of corruption in health care systems, both in public and private.

12. Inclusive Partnerships: • A multistakeholder approach with partnership & participation of all non-health ministries and communities. This approach would include partnerships with academic institutions, not for profit agencies, and health care industry as well.

13. Pluralism: • Patients who so choose and when appropriate, would have access to AYUSH care providers based on documented and validated local, home and community based practices. These systems would also have Government support in research and supervision to develop and enrich their contribution to meeting the national health goals and objectives through integrative practices.

14. Decentralization: • Decentralisation of decision making to a level as is consistent with practical considerations and institutional capacity. Community participation in health planning processes, to be promoted side by side.

15. Dynamism and Adaptiveness: • Constantly improving dynamic organization of health care based on new knowledge and evidence with learning from the communities and from national and international knowledge partners is designed.

16. Primary Care Services and Continuity of Care:“Health and Wellness Centers”. • Every family would have a health card that links them to primary care facility and be eligible for a defined package of services anywhere in the country. • The policy recommends that health centres be established on geographical norms apart from population norms. • To provide comprehensive care • Ayush • Digital Health

17. NHP2017: Goals & ObjectivesHealth Status and Programme Impact • 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.

18. Goals & Objectives: Health Status and Programme Impact • 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 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.

19. NHP2017: Goals & ObjectivesHealth 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.

20. NHP2017: Goals & ObjectivesHealth Systems Performance 2. 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.

21. NHP2017: Goals & ObjectivesHealth Systems strengthening • 1. Health finance • Increase health expenditure by Government as a percentage of GDP from the existing 1.15% 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. • 2. 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 norms in high priority districts (population as well as time to reach norms) by 2025.

22. NHP2017: Goals & ObjectivesHealth Systems strengthening •  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.

23. What are the positives? • The policy seeks to promote universal access to good quality healthcare services and a wide array of free drugs and diagnostics. • The proposed steps such as a health card for every family will certainly help improve health outcomes in India. • The recommended grading of clinical establishments and active promotion and adoption of standard treatment guidelines can also help improve the quality of healthcare delivery in India.

24. What are the lacunas? • The Policy reiterates health spend targets set by the erstwhile Planning Commission for the 12th Five Year Plan. • It fails to make health a justiciable right. • Whether Health should continue to be in the State List, or in the Concurrent List is not answered in the policy. • Lack of capacity to use higher levels of public funding for health. • Although a major capacity expansion to produce MBBS graduates took place between 2009 and 2015, this is unlikely to meet policy goals since only 11.3% of registered allopathic doctors were working in the public sector as of 2014.

25. What should be done? • More health professionals need to be deployed for primary care in rural areas. • Contracting of health services from the private sector may be inevitable in the short term. • No more time should be lost in forming regulatory and accreditation agencies for healthcare providers at the national and State levels. • To reduce high out-of-pocket spending, early deadlines should be set for public institutions to offer essential medicines and diagnostic tests free to everyone.

26. Health Planning in India 1.Bhore Committee,1946:- • Integration of services • Development of PHC’s • Changes in med. Education-Social physicians • Major National document.

27. Mudaliar Committee,1962Health survey & planning committee • To have fresh look at the health needs & resources. • Provide guidelines for national health planning. • To survey progress made in in the field of health since submission of Bhore Committee’s report. • To recommend future development and expansion of health services.

28. Cont… • Findings:- • Inadequate quality of service by PHC’s Recommendations :- • Consolidation of advances made in first 2 five year plans. • Strengthening of district hospital with specialist services. • Regional organizations under Regional Deputy or Assistant Directors. • Each PHC for > 40,000 population. • To improve quality of health care provided by the PHC’s. • Integration of medical & health services. • Constitution of All India Health Service on the pattern of Indian Administrative Services.

29. Chadah Committee,1963 Objective:- To study the arrangements necessary for maintenance phase of NMEP. Recommendations:- • Vigilance operations by general health services i.e. phc’s. • One basic health worker per 10,000 population. • BHW----MPW=Malaria + F.P.+ vital statistics • Family planning health assistants ---supervise work of 3-4 BHW’s. • At district level:- general health services were to take the responsibility of maintenance phase.

30. Mukerji committee,1965. Objective:-To review the strategy for family planning programme. Recommendations:- • Separate staff for family planning programme. • De-link malaria activities from family planning.

31. Mukerji committee,1966 • Objective:- To examine the issues of paucity funds and burden on state governments. Committee worked out the details of the Basic Health Worker

32. Jungalwala committee,1967(committee on integration of Health services) Objectives:- • Integration of health services • Elimination of private practice by government doctors. “integrated health services” as defined by committee, • A service with unified approach for all problems instead of a segmented approach for different problems. • Preventive & curative care under unified manner at all levels.

33. Cont…. • Main steps recommended towards integration:- • Unified cadre • Common seniority • Recognition for extra qualification • Equal pay for equal work • Special pay for specialized work • No private practice, and good service conditions. “Integration should be a process logical evolution rather than revolution”

34. Kartar Singh committee,1973“committee on Multipurpose Workers under health & Family Planning” Objectives:- to study & make recommendations on • Structure for integrated services. • Feasibility of having multipurpose,bipurpose workers in the field. • Training requirements of such workers • Utilization of mobile service units.

35. Main Recommendations • ANM-----by “Female health workers”. • BHW,malaria surveillance workers,vaccinators,health education assistants(trachoma)& F.P.health assistants--------by“Male Health Workers” • Programme to be started in states where malaria is in maintenance phase & small pox has been controlled. • One PHC for 50,000 population. • Each PHC should be divided into 16 subcentres. • Each subcentre ---1 male & 1 female health worker. • 1 male health supervisor to supervise the work of 3-4 male health workers. & 1 female health supervisor to supervise 4 female health workers.

36. Cont…. 8. Lady health visitors ------female health supervisors. 9. Doctor in charge of PHC should have the overall charge of all staff.

37. Shrivastav committee,1975(Medical education & support manpower) Objectives:- • To devise suitable curriculum for training a cadre of health assistants. • To suggest steps for improving the existing medical educational process. • To make any other suggestions to realise the above objectives.

38. Recommendations • Creation of bands of Para-professional & semi-professional health workers from within the community itself. • Establishment of 2 cadres of health workers namely multipurpose health workers and health assistants. • Development of Referral Service Complex. • Establishment of a medical & health education commission. • At the end of 6th plan---1 male & 1 female health worker should be available for every 5,000/- population.

39. Rural Health Scheme,1977 • Programme of training of community health care workers---steps:- • Involvement of medical college:- reorienting medical education to the needs of rural people. • Reorientation training of multipurpose workers into unipurpose workers. Health for All by 2000 AD-

40. Planning Commission • Established in 1950 • Objectives:- • To assess resources of the country • To draft developmental plans • Effective utilization of available resources Planning commission consists of • Chairman • Deputy Chairman • Five members

41. Major divisions To scrutinize & Analyze various schemes and projects to be incorporated in the five year plans

42. Health Sector PlanningHealth sector----sub-sectors • Water supply & sanitation • Control of communicable diseases • Medical education, training and research. • Medical care including hospitals, dispensaries & primary health centres. • Public health services • Family planning • Indigenous systems of medicine.

43. Five year plans • Objectives :- • Control or eradication of major communicable diseases • Strengthening of the basic health services through the establishment of primary health centres and sub-centres • Population control • Development of health manpower resources.

44. Eleventh five year plan(2007-2012) • Goals for the Eleventh five year plan:- • Reducing MMR to 1 per 1000 live births. • Reducing IMR to 28 per 1000 live births. • Reducing TFR to 2.1 • Providing clean drinking water for all by 2009. • Reducing malnutrition among children of age group 0-3 to half its present level. • Reducing anaemia among women and girls by 50%. • Raising the sex ratio for age group 0-6 to 935 by 2011-12 and 950 by 2016-17.

45. Thrust areas to be pursued during 11th five year plan • Improving health equity • NRHM • NUHM • Adopting a system centric approach rather than a disease-centric approach. • Strengthening health system through up gradation of infrastructure and PPP. • Converging all programmes.decentalized participatory approach. • Increasing survival • Gender sensitive health care • IMNCI • Taking full advantage of local enterprise for solving local health problems. • AYUSH • Role of RMP’s • TBA’s--------SBA’s • Low cost indigenous technology.

46. Cont….. • Preventing indebtedness due to expenditure on health/protecting the poor from health expenditure. • Creating mechanisms for health insurance. • Health insurance for un-organized sector • Decentralizing governance:- • Increasing the role of PRIs,NGOs,and civil society. • Establishing e-Health :- • Adopting IT for governance. • Establishing e-enabled HMIS • Increasing role of Telemedicine. • Improving access to and utilization of essential and quality health care:- • Flexible norms • Reduce travel time in EmOC • IPHS for PHC’s • Accrediting private health care • Mirroring of centres of excellence like AIMS.

47. Cont…. • Increasing focus on health human resources • Focusing on excluded/neglected areas. • Taking care of older persons • Reducing disability • Providing humane mental health services • Providing oral health services. • Enhancing efforts at disease reduction. • Providing focus to health systems and biomedical research.

48. Organization of health care in India central level Concurrent List Union List Additional secretary & commissioner family welfare Central council of health/family welfare Family welfare programme National health & FP Org. Population council of India Health Services

49. Health Services • International health & quarantine • Medical education & research • Medical stores & depots • Drug Quality • National health programmes • Health education & information • National health Institutes

50. Union List • International health relations and administration of port quarantine. • Administration of central institutes. • Promotion of research through research centers. • Regulation & development of medical,pharmaceutical,dental & nursing professionals. • Establishment & maintenance of drug standards • Census, and collection & publication of other statistical data. • Immigration & emigration • Regulation of labour in working of mines and oil fields. • Coordination with states and other ministries for promotion of health.