SUBJECT-PHARMACEUTICAL AND HEALTHCARE SECTOR

KEYUR D VASAVA

Module.1 OVERVIEW OF HEALTHCARE SERVICES IN INDIA: 1. AN INTRODUCTION TO H EALTH SERVICES IN INDIA THROUGH FIVE YEAR P LANS
Eleventh Five-Year Plan, 20072012 Health

Reduce infant mortality rate to 28 and maternal mortality ratio to 1 per 1000 live births Reduce Total Fertility Rate to 2.1 Provide clean drinking water for all by 2009 and ensure that there are no slip-backs Reduce malnutrition among children of age group 0-3 to half its present level Reduce anaemia among women and girls by 50% by the end of the plan

Eleventh Five Year Plan with the following Terms of Reference: (i) To review existing scenario of Public Health Services (including Water & Sanitation) in urban and rural areas considering regional & inter district disparities and with a view to provide universal access to equitable, affordable and quality health care which is accountable at the same time responsive to the needs of the people and also achieve goals set under the National Health Policy and the Millennium Development Goals. (ii) To review the goals, objectives, strategies and expected outcomes of the National Rural Health Mission by the end of the eleventh five year period (2012) at all levels. (iii) To review the implementation of major health and family welfare programmes, functioning of infrastructure and manpower in rural and urban areas, and suggest measures for rationalizing/restructuring the infrastructure, strategies for improving efficiency and for the delivery of services with a special focus on women & children. (iv) To review the challenges of the immediate future such as aging population increased disease burden on account of new infections and non-communicable diseases that have the potential to impoverish the poor. (v) To review the mechanism for screening and referral of patients, so that they receive appropriate care at all levels. (vi)To review disease control programmes and disease surveillance mechanism in the country, its capability to provide up-to-date information for effective timely response to prevent/limit disease out breaks and to provide effective relief measures.

(Vii) Identify year-wise quantifiable goals and specific road map of the NRHM and also suggest method of concurrent evaluation of NRHM. (viii) To suggest modification in policies, priorities and programmes during 11th Plan period in relation to: (a) Priority areas of research to investigate alternative strategies; (b) Mid-course correction of ongoing activities; (c) New initiatives; (d) Strategies to improve quality and coverage of services at affordable cost, to cope with existing, reemerging and new challenges in communicable diseases, emerging problems of non-communicable diseases due to increasing longevity, life style changes and environmental degradation; (e) Provide all these services through NRHM and secondary health care system in an integrated fashion; (f) Improve disease surveillance, HMIS, effective timely response. (ix) To indicate manpower requirement and financial outlays required for implementation of these programmes during the 11th Plan period; (x) To deliberate and give recommendations on any other matter relevant to the topic.

2. HEALTHCARE SYSTEM IN INDIA

A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations. Healthcare in India features a universal health care system run by the constituent states and territories of India. The Constitution charges every state with "raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. However, the government sector is understaffed and underfinanced; poor services at state-run hospitals force many people to visit private medical practitioners. Government hospitals, some of which are among the best hospitals in India, provide treatment at taxpayer expense. Most essential drugs are offered free of charge in these hospitals. Government hospitals provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in India) costs a onetime fee of rupees 10 (around 20 cents US) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually much less than the private

sector. For instance, a patient is waived treatment costs if he is below poverty line. Another patient may seek for an air-conditioned room if he is willing to pay extra for it. The charges for basic in-hospital treatment and investigations are much less compared to the private sector. The cost for these subsidies comes from annual allocations from the central and state governments. Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses. Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals). In recent times, India has eradicated mass famines, however the country still suffers from high levels of malnutrition and disease especially in rural areas. Water supply and sanitation in India is also a major issue in the country and many Indians in rural areas lack access to proper sanitation facilities and safe drinking water. However, at the same time, India's health care system also includes entities that meet or exceed international quality standards. The medical tourism business in India has been growing in recent years and as such India is a popular destination for medical tourists who receive effective medical treatment at lower costs than in developed countries.

OR
A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations. There is a wide variety of health care systems around the world, with as many histories and organizational structures as there are nations. In some countries, health care system planning is distributed among market participants. In others, there is a concerted effort among governments, trade unions, charities, religious, or other co-ordinate bodies to deliver planned health care services targeted to the populations they serve. However, health care planning has been described as often evolutionary rather than revolutionary.
Goals

The goals for health systems, according to the World Health Organization, are good health, responsiveness to the expectations of the population, and fair financial contribution. Progress towards them depends on how systems carry out four vital functions: provision of health care services, resource generation, financing, and stewardship. Other dimensions for the evaluation of health care systems include quality, efficiency, acceptability, and equity. They have also been described in the United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness

Providers

Health care providers are institutions or individuals providing health care services. Individuals including health professionals and allied health professions can be self-employed or working as an employee in a hospital, clinic, or other health care institution, whether government operated, private for-profit, or private not-for-profit (e.g. non-governmental organization). They may also work outside of direct patient care such as in a government health department or other agency, medical laboratory, or health training institution. Examples of health workers are doctors, nurses, midwives, paramedics, dentists, medical laboratory technicians, therapists, psychologists, pharmacists, chiropractors, optometrists, community health workers, traditional medicine practitioners, and others. Financial resources

There are generally five primary methods of funding health care systems: 1. 2. 3. 4. 5. general taxation to the state, county or municipality social health insurance voluntary or private health insurance out-of-pocket payments donations

Management

The management of any health care system is typically directed through a set of policies and plans adopted by government, private sector business and other groups in areas such as personal health care delivery and financing, pharmaceuticals, health human resources, and public health. Public health is concerned with threats to the overall health of a community based on population health analysis. The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). Public health is typically divided into epidemiology, biostatistics and health services. Environmental, social, behavioral, and occupational health are also important subfields. Today, most governments recognize the importance of public health programs in reducing the incidence of disease, disability, the effects of aging and health inequities, although public health generally receives significantly less government funding compared with medicine. For examply, most countries have a vaccination policy, supporting public health programs in providing vaccinations to promote health. Vaccinations are voluntary in some countries and mandatory in some countries. Some governments pay all or part of the costs for vaccines in a national vaccination schedule. The rapid emergence of many chronic diseases, which require costly long-term care and treatment, is making many health managers and policy makers re-examine their health care delivery practices. An important health issue facing the world currently is HIV/AIDS. Another major public health concern is diabetes. In 2006, according to the World Health Organization, at

least 171 million people worldwide suffered from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will double. A controversial aspect of public health is the control of tobacco smoking, linked to cancer and other chronic illnesses. Antibiotic resistance is another major concern, leading to the reemergence of diseases such as tuberculosis. The World Health Organization, for its World Health Day 2011 campaign, is calling for intensified global commitment to safeguard antibiotics and other antimicrobial medicines for future generations.
Special health care systems

Occupational safety and health School health services Military medicine

Health care by India

In the greater India, the hospitals are run by government, charitable trusts and by private organizations. The government hospitals in rural areas are called the (PHC)s primary health centre. Major hospitals are located in district head quarters or major cities. Apart from the modern system of medicine, traditional and indigenous medicinal systems like Ayurvedic and Unani systems are in practice throughout the country. The Modern System of Medicine is regulated by the Medical Council of India, whereas the Alternative systems recognized by Government of India are regulated by the Department of AYUSH (an acronym for Ayurveda, Yunani, Siddha & Homeopathy) under the Ministry of Health, Government of India. PHCs are non-existent in most places, due to poor pay and scarcity of resources. Patients generally prefer private health clinics. These days some of the major corporate hospitals are attracting patients from neighboring countries such as Pakistan, countries in the Middle East and some European countries by providing quality treatment at low cost. In 2005, India spent 5% of GDP on health care, or US$36 per capita. Of that, approximately 19% was government expenditure. OR
Indigenous or traditional medical practitioners continue to practice throughout the country. The two main forms of traditional medicine practiced are the ayurvedic (meaning science of life) system, which deals with causes, symptoms, diagnoses, and treatment based on all aspects of well-being (mental, physical, and spiritual), and the unani (so-called Galenic medicine) herbal medical practice. A vaidya is a practitioner of the ayurvedic tradition, and a hakim (Arabic for a Muslim physician) is a practitioner of the unani tradition. These professions are frequently hereditary. A variety of institutions offer training in indigenous medical practice. Only in the late 1970s did official health policy refer to any form of integration between Western-oriented medical personnel and indigenous medical practitioners. In the early 1990s, there were ninety-eight ayurvedic colleges and seventeen unani colleges operating in both the governmental and nongovernmental sectors.

10 ways to improve India's healthcare system

1. Develop and implement national standards for examination by which doctors, nurses and
pharmacists are able to practice and get employment.

2. Rapidly develop and implement national accreditation of hospitals; those that

do not comply would not get paid by insurance companies. However, a performance incentive plan that targets specific treatment parameters would be a useful adjunct.

3. Obtain proposals from private insurance companies and the government on ways to provide
medical insurance coverage to the population at large and execute the strategy. It is healthy to have competition in healthcare, and provide health insurance to the millions who cannot afford it.

4. Utilize and apply medical information systems that encourage the use of evidence-based
medicine, guidelines and protocols as well as electronic prescribing in inpatient and outpatient settings. This is possible though the implementation of the EHR; this will, in time, encourage healthcare data collection, transparency, quality management, patient safety, efficiency, efficacy and appropriateness of care.

5. Perverse incentives between specialists, hospitals, imaging and diagnostic centres on the one
hand and referring physicians on the other need be removed and a level of clarity needs to be introduced.

6. Develop multi-specialty group practices that have their incentives aligned with those of
hospitals and payers. It is much easier to teach the techniques of sophisticated medical care to a group of employed physicians than it is to physicians as a whole. It is also important that doctors are paid adequately for what they do.

7. Encourage business schools to develop executive training programmes in healthcare, which

will effectively reduce the talent gap for leadership in this area.

8. Revise the curriculum in medical, nursing, pharmacy and other schools that train healthcare
professionals, so that they too are trained in the new paradigm.

9. Develop partnerships between the public and private sectors that design newer ways to
deliver healthcare. An example of this would include outpatient radiology and diagnostic testing centers.

10. The government should appoint a commission which makes recommendations for the
healthcare system and monitors its performance.

3. LEVELS OF H EALTH CARE, PRIMARY, SECONDARY AND TERTIARY HEALTH CARE

HEALTH CARE is the diagnosis, treatment and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, dentistry, nursing, pharmacy and allied health. The exact configuration of health care systems varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; and well maintained facilities and logistics to deliver quality medicines and technologies.

What are the 3 levels of health care

Primary health care is about preventing illness or disability. This would include Well Women's Clinics, child immunization programs, malaria prevention and that sort of thing.

Secondary health care is where a patient is ill and is treated, usually by nurses and doctors. Treatment of diabetes, high blood pressure, bronchitis and minor fractures are some examples of secondary health care.

Tertiary health care is where things have gone wrong and long term care and rehabilitation programs are used, for instance if someone had a double amputation, they would need artificial limbs and physiotherapy and possibly adaptations to the home.

4. REVIEW OF PRIMARY H EALTHCARE IN INDIA

PRIMARY HEALTH CARE means ...essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individual and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the countrys overall health system, of which it is the central function and main focus, and the overall social and economic development of the community. It is the first level of contact Of individuals, the family and community with the national health system bringing care as close as possible to where people live and work, and constitutes the first elements of a continuing health care process. Primary health care is provided by city and district hospitals and rural primary health centers (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses. Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluka headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).

P RIMARY SERVICES
Health care facilities and personnel increased substantially between the early 1950s and early 1980s, but because of fast population growth, the number of licensed medical practitioners per 10,000 individuals had fallen by the late 1980s to three per 10,000 from the 1981 level of four per 10,000. In 1991 there were approximately ten hospital beds per 10,000 individuals. For comparison, in China there are 1.4 doctors per 1000 people. Primary health centers are the cornerstone of the rural health care system. By 1991, India had about 22,400 primary health centers, 11,200 hospitals, and 27,400 clinics. These facilities are part of a tiered health care system that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast majority in the countryside. Primary health centers and subcenters rely on trained paramedics to meet most of their needs. The main problems affecting the success of primary health centers are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas. In addition, the integration of health services with family planning programs often causes the local population to perceive the primary health centers as hostile to their traditional preference for large families. Therefore, primary health centers often play an adversarial role in local efforts to implement national health policies. According to data provided in 1989 by the Ministry of Health and Family Welfare, the total number of civilian hospitals for all states and union territories combined was 10,157. In 1991 there were a total of 811,000 hospital and health care facilities beds. The geographical distribution of hospitals varied according to local socio-economic conditions. In India's most populous state, Uttar Pradesh, with a 1991 population of more than 139 million, there were 735 hospitals as of 1990. In Kerala, with a 1991 population of 29 million occupying an area only one-seventh the size of Uttar Pradesh, there were 2,053 hospitals. Although central government has set a goal of health care for all by 2000, hospitals are distributed unevenly. Private studies of India's total number of hospitals in the early 1990s were more conservative than official Indian data, estimating that in 1992 there were 7,300 hospitals. Of this total, nearly 4,000 were owned and managed by central, state, or local governments. Another 2,000, owned and managed by charitable trusts, received partial support from the government, and the remaining 1,300 hospitals, many of which were relatively small facilities, were owned and managed by the private sector. The use of state-of-the-art medical equipment was primarily limited to urban centers in the early 1990s. A network of regional cancer diagnostic and treatment facilities was being established in the early 1990s in major hospitals that were part of government medical colleges. By 1992 twenty-two such centers were in operation. Most of the 1,300 private hospitals lacked sophisticated medical facilities, although in 1992 approximately 12% possessed state-of-the-art equipment for diagnosis and treatment of all major diseases, including cancer. The fast pace of development of the private medical sector and the burgeoning middle class in the 1990s have led to the emergence of the new concept in India of establishing hospitals and health care facilities on a for-profit basis. By the late 1980s, there were approximately 128 medical colleges - roughly three times more than in 1950. These medical colleges in 1987 accepted a combined annual class of 14,166

students. Data for 1987 show that there were 320,000 registered medical practitioners and 219,300 registered nurses. Various studies have shown that in both urban and rural areas people preferred to pay and seek the more sophisticated services provided by private physicians rather than use free treatment at public health centers.
PRIMARY HEALTH CARE

It has been defined as an essential health care which should be based on practical, scientifically sound and socially acceptable methods and technology. It should be made universally accessible to the individuals and the family in the community through their full participation. It is to be made available at a cost which the community and the country can afford to maintain at every stage of its development in a spirit of self-reliance and self-determination. Primary health care is the first level of contact of the individuals, the family and the community with the national health system bringing health care as close as possible to where the people live and work. It constitutes the first element of the process of continuing health care, and this should get full support from the rest of the health system. This support would be required in the following areas: (a) consultation on health problems; (b) referral of patients to local or other specialized institutions; (c) supportive supervision and guidance; and (d) logistic support and supplies. For achieving success in HFA development, at least eight essential components of primary health care need to be properly implemented. For this the cooperation and support of other social and economic development sectors, such as education, social and women's welfare, food and agriculture, animal husbandry, water resources, housing, rural development, energy, environmental protection, industry, communication, etc. would be vital.
HEALTH SYSTEM INFRASTRUCTURE

The country is divided into 22 major States and 9 smaller union territories which inturn are divided into administrative districts. At present, there are 431 districts. Each district is divided into subdistricts or talukas, under which are situated the community development blocks. There are about 6,000 community development blocks in the country. As mentioned earlier, over the past three decades the health services infrastructure and health care facilities have been expanded considerably. It is aimed to further improve the facilities as noted below
Facilities at Village Level

In a village, for about 1,000 populations, there will be one health guide and one trained dai or traditional birth attendant (TBA); both will be selected from the community. They will be tra;ned at the level of the primary health centre (PHC) and the sub-centre. These two village level functionaries are to receive technical support and continuing education from *he multi-purpose health workers (male and female) posted at the sub-centre. Other administrative control and supervision should ideally be carried out by the village health committee or the village panchayat.

Facilities at PHC Level

At present there is one PHC in each community development block, which covers about 1, 00,000 or more, population. It is aimed to establish one PHC for every 30,000 population by the year 1990. Many rural dispensaries are being upgraded to create the subsidiary health centers or these new PHCs. Each new PHC will have one medical officer, two health assistants - one male and one female, and the health workers and other supporting staff. For strengthening preventive and promotive aspects of health care, a new non-medical post called community health officer (CHO) will be provided at each new PHC. To date, there are about 11,000 PHCs (both old and new combined).
Facilities at Community Health Centre

For a successful primary health care programme, effective referral support is to be provided. For this purpose one community health centre (CHC) will be established for every 1,00,000 population, and this centre will provide the main specialist services. The CHCs will be established either by upgrading the subdistrict /taluka hospitals or some of the block level PHCs, or by creating a new centre wherever absolutely needed.
Facilities at District Level

District health organization is to be appropriately strengthened to cater to the needs of the expanding rural health and family welfare programmes. Not only the planning and implementation and monitoring of health and family welfare programmes are to be carried ou* at the district level (preferably on a decentralized basis), all the referral services from the periphery i.e. PHCs. community health centers and taluka hospitals, are to be attended to satisfactorily.
ESSENTIAL COMPONENTS OF PRIMARY HEALTH CARE

In the Alma Ata Declaration, it is stated that at least the following components should be included in primary health cars: 1. Education of the people about prevailing health problems and methods of preventing and controlling them. 2. Promotion of food supply and proper nutrition. 3. Adequate supply of safe water and basic sanitation. 4. Maternal and child health care and family planning. 5. Immunization against major infectious diseases. 6. Prevention and control of locally endemic diseases. 7. Appropriate treatment of common diseases and injuries. 8. Provision of essential drugs.

5. NATIONAL RURAL & URBAN H EALTH MISSION

National urban health mission

The NUHM will meet health needs of the urban poor, particularly the slum dwellers by making available to them essential primary health care services. This will be done by investing in highcaliber health professionals, appropriate technology through PPP, and health insurance for urban poor. Recognizing the seriousness of the problem, urban health will be taken up as a thrust area for the Eleventh Five Year Plan. NUHM will be launched with focus on slums and other urban poor. At the State level, besides the State Health Mission and State Health Society and Directorate, there would be a State Urban Health Programmed Committee. At the district level, similarly there would be a District Urban Health Committee and at the city level, a Health and Sanitation Planning Committee. At the ward slum level, there will be a Slum Cluster Health and Water and Sanitation Committee. For promoting public health and cleanliness in urban slums, the Eleventh Five Year Plan will also encompass experiences of civil society organizations (CSO) working in urban slum clusters. It will seek to build a bridge of NGOGO partnership and develop community level monitoring of resources and their rightful use. NUHM would ensure the following:

Resources for addressing the health problems in urban areas, especially among urban poor.

Need based city specific urban health care system to meet the diverse health needs of the urban poor and other vulnerable sections.

Partnership with community for a more proactive involvement in planning, implementation, and monitoring of health activities. Institutional mechanism and management systems to meet the health-related challenges of a rapidly growing urban population.

Framework for partnerships with NGOs, charitable hospitals, and other stakeholders.

Two-tier system of risk pooling: (i) womens Mahila Arogya Samiti to fulfil urgent hard-cash needs for treatments; (ii) a Health Insurance Scheme for enabling urban poor to meet medical treatment needs. NUHM would cover all cities with a population of more than 100000. It would cover slum dwellers; other marginalized urban dwellers like rickshaw pullers, street vendors, railway and

bus station coolies, homeless people, street children, construction site workers, who may be in slums or on sites. The existing Urban Health Posts and Urban Family Welfare Centres would continue under NUHM. They will be marked on a map and classified as the Urban Health Centres on the basis of their current population coverage. All the existing human resources will then be suitably reorganized and rationalized. These centres will also be considered for upgradation. Intersectoral coordination mechanism and convergence will be planned between the Jawaharlal Nehru National Urban Renewal Mission (JNNURM) and the NUHM.
OR

Union Minister for Health and Family Welfare Ghulam Nabi Azad on Wednesday said the government was in the process of formulating the national urban health mission. "We are now in the process of formulating the national urban health mission which will take care of infrastructure needs of district and subdivisional level besides divisional headquarter and state capitals," he said. He was speaking at the inauguration of a two-day conference of state health ministers. There has been improvement in health infrastructure, referral transport and augmentation in human resources. Under the Janani Suraksha Yojana, the coverage of beneficiaries has increased from 573,000 in 2005-06 to 10 million in 2009-10, said Azad. Presenting his ministry's report card for 2010, the minister said institutional deliveries had gone up from 47 per cent to 72 per cent during this period. Highlighting the success of the polio drive, the health minister said that with the introduction of the biovalent polio vaccine, only 42 cases were reported in 2010, versus more than 700 cases in 2009. Speaking on the occasion, Chief Minister of Andhra Pradesh, N Kiran Kumar Reddy said his state government intends to boost expenditure in the health sector. He said the health budget of his state was Rs 1,680 crore in 2004 which has now gone up to Rs 4,300 crore. The Andhra Pradesh government, Reddy said, was concentrating on strengthening government hospitals and staff by giving more incentives to doctors and paramedics, he added. Over the last six years, the government has provided Rs 53,000 crore to the states under National Rural Health Mission. The utilisation of funds in all states under National Rural Health Mission has gone up from Rs 4,873 crore in 2005-06 to Rs 14,264 crore in 2009-10.
National Rural Health Mission

THE VISION OF THE MISSION

To provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. 18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur , Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa , Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. To raise public spending on health from 0.9% GDP to 2-3% of GDP, with improved arrangement for community financing and risk pooling. To undertake architectural correction of the health system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the country. To revitalize local health traditions and mainstream AYUSH into the public health system. Effective integration of health concerns through decentralized management at district, with determinants of health like sanitation and hygiene, nutrition, safe drinking water, gender and social concerns. Address inter State and inter district disparities. Time bound goals and report publicly on progress. To improve access to rural people, especially poor women and children to equitable, affordable, accountable and effective primary health care. To achieve these goals NRHM will: Facilitate increased access and utilization of quality health services by all. Forge a partnership between the Central, state and the local governments. Set up a platform for involving the Panchayati Raj institutions and community in the management of primary health programmes and infrastructure. Provide an opportunity for promoting equity and social justice. Establish a mechanism to provide flexibility to the states and the community to promote local initiatives. Develop a framework for promoting inter-sectoral convergence for promotive and preventive health care. The Objectives of the Mission Reduction in child and maternal mortality

Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services addressing womens and childrens health and universal immunization Prevention and control of communicable and non-communicable diseases, including locally endemic diseases. Access to integrated comprehensive primary health care. Population stabilization, gender and demographic balance. Revitalize local health traditions & mainstream AYUSH. Promotion of healthy life styles. The core strategies of the Mission Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services. Promote access to improved healthcare at household level through the female health activist (ASHA). Health Plan for each village through Village Health Committee of the Panchayat. Strengthening sub-centre through better human resource development, clear quality standards, better community support and an untied fund to enable local planning and action and more Multi Purpose Workers (MPWs). Strengthening existing (PHCs) through better staffing and human resource development policy, clear quality standards, better community support and an untied fund to enable the local management committee to achieve these standards. Provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard. (IPHS defining personnel, equipment and management standards, its decentralized administration by a hospital management committee and the provision of adequate funds and powers to enable these committees to reach desired levels) Preparation and implementation of an inter sector District Health Plan prepared by the District Health Mission, including drinking water, sanitation, hygiene and nutrition. Integrating vertical Health and Family Welfare programmes at National, State, District and Block levels. Technical support to National, State and District Health Mission, for public health Management

Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision. Formulation of transparent policies for deployment and career development of human resource for health. Developing capacities for preventive health care at all levels for promoting healthy life style, reduction in consumption of tobacco and alcohol, etc. Promoting non-profit sector particularly in underserved areas. The supplementary strategies of the mission Regulation for Private sector including the informal Rural Medical Practitioners (RMP) to ensure availability of quality service to citizens at reasonable cost. Promotion of public private partnerships for achieving public health goals. Mainstreaming AYUSH revitalizing local health traditions. Reorienting medical education to support rural health issues including regulation of medical care and medical ethics. Effective and visible risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care. OR

The purpose of NRHM among other things was to strengthen the primary health centres (PHCs) and sub-centers and creates a network of rural hospitals. However it was felt that several developments since the launch of the NRHM in April 2005 point to increased privatization of health care services. For instance in several states the NRHM under the garb of better health management opened up space to outsourcing and privatization of PHCs and subcentres. The NRHM is criticized for adopting a system of Indian Public Health Standards which was seen as having severe limitations. While it defined the minimum manpower requirement and the equipment and infrastructure needed to attain a set of well defined health outcomes the attempts to achieve these were not comprehensive in scope and were biased largely towards reproductive and child health. The IPHS was adopted for CHCs, PHCs and district hospitals as well. However the emphasis was still on purchasing equipment and attaining standards of infrastructure development rather than raising the level of overall service provision. The policy in some states of allowing public participation in the monitoring and administration of health care services also backfired. The Rogi Kalyan samities that were started with the intent of greater public participation in the health care system degenerated into a system of cost recovery with the introduction of user fee for many services in government hospitals. Donor agencies pushed for the user -fee system and this resulted in a reduction of state investment in

the maintenance of health care facilities. The public participation has been trivialized: it translated into better access for the privileged and the politically powerful. Urban health statistics revealed that in many states the key indicators such as urban infant mortality rate had remained stagnant or their trend had even reversed. The specific vulnerability of urban slum dwellers the lack of basic amenities and health services for them was an area yet to be addressed. The NRHM was formally empowered to cover urban slums but in reality the coverage was negligible. Whatever urban component was there in health care ,it was in the RCH plans in a limited manner.There was no equivalent plan to set up PHCs,CHCs or sub centres in urban areas. ASHA plan conceived as an important component of NRHM was a let down due to deemphasizing of the workers' curative and symptomatic roles and the piece rate system of payment .While the strategy of deploying ASHAs was plausible what had not been anticipated was the inability of the existing departmental structures to implement such a large scale mobilization and the absence of support structures. The implementation of the ASHA plan was poor. The NRHM was a compulsion to show the pro-poor face of the new government. It has been found during a study conducted by Jan Swasthya Abhiyan that most of the ASHAs had yet to start work; the Anganwadi worker or the Auxiliary Nurse Midwife allocated them work. Under the NRHM the ASHA was required to be accountable to the community and not subservient to the ANM or AWW.Dalit health workers were discriminated against. In MP nearly 50% of the PHCs surveyed were being managed by non medical staff, in Bihar 30%, in Rajasthan 25% and in Jharkhand 12%.The main problems plaguing PHCs related to improper drug supply and shortage of staff. In many of the states the PHCs and even some of the CHCs had been contracted out to NGOs under the managed care approach. This system which is in vogue in Bihar, Karnataka and Arunchal Pradesh entailed the offering of a specified package of services. There is no notion of decentralization and community management. In Gujarat under the Chiranjeevi Programme private clinics are reimbursed at fixed rates for institutional deliveries and emergency obstetric care services. The government has also contracted out peripheral health facilities and has a proposal to contract out district hospitals to corporates.Some of the private health insurance schemes supported by state governments had failed. However in some states such as Tamil Nadu and West Bengal the partnership is working well. The core of the public health system stayed within the public domain and only some of the ancillary services were contracted out. According to Jan Kalyan Abhiyan a vast network of government run health subcentres and PHCs supported by CHCs and district hospitals is required along with a large community health-worker force, the expansion of nursing staff and the upgrading of their skills. The notion of primary health care continues to be limited in that it is applied to RCH and a few disease control programmes.There is still reluctance to move towards the goal of comprehensive primary health care. The health policy is silent on is the need to set up a rational drug policy. All policies including NRHM had glossed over this aspect despite the fact that nearly 2/3 of all health costs go into drugs. There is no regulation of the prices of essential drugs whose list had been brought down to 30 in 2002 from 347 in 1977.

There has been lot of importance given to two vaccination initiatives-pulse polio and universal Hepatitis B vaccination. More than Rs 1000 crore is spent annually on the pulse polio programme while the budget for other vaccines in the National Immunization Programme in 2005-06 was only Rs 327 crore. The objectives of any health policy have to be seen in the light of the Alma Ata declaration where health was not just a desired goal but one of the main harbingers of equity in society. The government's intent in bringing changes to the health care system may be good but their implementation seems to be directed by donor directed priorities.

MODULE 2. OVERVIEW OF NATIONAL HEALTH POLICY 2002:

1. OBJECTIVES