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Health system by- Dileep Mavalankar
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Health system by- Dileep Mavalankar


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  • 1. Overview of Health Service Delivery in India – Issues and problems
    Dr. DileepMavalankar
    Indian Institute of Public Health (IIPH), Gandhinagar
    ( Public Health Foundation of India)
    Prof. IIM Ahmebad ( on leave)
  • 2. India is diverse – overview in 20 minutes is not simple
    Kashmir to Kanyakumari – Dwarka to Arunachal – languages, culture, economy, power and gender, age, …..
    Political parties – governance- governments – people
    Lands – climate – environment – water… different
    But one nation – one constitution – one supreme court -…. Similar problems…..!!!!
  • 3. Under 5 mortality will reach 54, MDG target is 38
  • 4. MMR decline – will reach 153 by 2015, MDG target is 100
    Can we meet any targets ???
    In the past we have not met many health goals set by planning commission
  • 5. Causes of Under-five mortality – infections and birth related causese
  • 6. Historical development
    Ayurveda and long local healing tradition
    Historically “civil hospitals”, “district Hospitals” ..Leprosy, TB, ID hospitals, charitable hospitals
    Bhorecommittee inspired – planning commission funded – Primary Health Care System – PHC, SC, CHC –
    There is a central government driven – state government funded public system
  • 7. Public health system was built on the British health development pattern
    Epidemic act 1897
    Madras nursing act 1928….. Bengal nursing act 1937
    Sanitary commissions, “sanitary inspector”
    Birth and death registration…
    Medical schools (LMP) and then medical colleges..MBBS .. Many docs trained in Britain
  • 8. Current Health Delivery system – As a “Jugad”
    Jugad is make-shift arrangement done by the poor, of the poor, for the poor
    Make-shift health system – many things on paper but not on ground.
    Hotchpotch – mix of public – private – insurance – NGO – Traditional medicine…
    ( may be like Bhel-puri !!!)
  • 9. The current scenario- mega trends
    Gross under- investments in public health care system – curative and preventive -0.9% to 1.14% of GDP
    Poor management capacity and practices -
    Neglect of Human Resource management – hardly any HR planning. NO HR cell / division at any level – no qualified HR managers in health department
    Drive by private sector – major provider of care – major attractor of top level HR (Docs)
  • 10. Professional Councils - mismanaged
    Medical and nursing councils small – unrepresentative – corrupt – but powerful
    No oversight from government
    Dominated by private practioners
    Structure oriented norms rather than process oriented
    Not much regulation of practice of health care
    No alignment of curricula with need of the public and majority health system.
  • 11. Government system – fund starved – bound by bureaucratic procedures, political interference, lack of management
    Gross under investment – 1% of GDP – need 4-5%
    In UK NHS has 1 GP per 1-2000 population – Indian PHCs have 1 MO for 15-30,000 population.
    Sweden has 1 public nurse:100 people – India 1:1000
    Medicine/supplies budget in PHC 2- 3 Rs per capita/yr
    Buildings dilapidated, equipment not available or working, no supplies…….
    Health workers – few and absent – un-welcoming – frustrated, …… old
    Very little research – funded by state governments
  • 12. Underlying causes of there problems
    Lack of political commitment to health – education and social welfare – disinterested political class, - health is low priority ministry
    Too much commitment to economic development, business, private market development, Industrialization…… IIP numbers produced every quarter – birth and death takes 1 years to compile in SRS
    Neglect of public health and lack of public health leadership -
  • 13. Underlying causes (continued)
    “TajMahalSysdrome” – building monuments rather than building human resources - “AIIMS like institutions” – rather than district and sub-district hospitals, PHCs….
    Lack of “equality”, PM/CM are tread in private hospitals – poor go to public hospitals.
    Lack of concern for the poor,
    Lack of political / social dialogue on health and social- welfare - more of slogans and advertisements rather than real programs
  • 14. More operational reasons
    No public health cadre at central or state level – any doctor can be posted as public health officer
    “Babu- Neta” syndrome - IAS/State Ad. Service - officers and politicians decide public health priorities and programs…..
    Lack of standards in much of health care – “how many patients can a doc see in 1 hour”, what infection rate is too high ?? What is an epidemic?? What is deaths due to malaria?
  • 15. Who will bell the Cat ?? Who will say that emperor does not have clothes??
    Purposeful denial of the PH problems – no deaths in Chikungunya in spite of 3000 additional death in Ahmedabad. WHO and other international agencies not bothers to finding out what is the truth – just helping the government in saying what it want to say
    Policies are made in air-conditioned rooms for rural scorching realities – blood banking policy
  • 16. New and emerging problems
    Health is understood as medical care
    Medical care is what “cardiologists advise”
    Ministers seem to hear what super-specialists - high profile private sector doctors are saying –
    Company – interest driven policies – CII - FICCI
  • 17. Lack of data and understanding of data
    No birth and death recording – RGI has become an administrative position
    No cause of death recording & analysis on regular basis
    Not even maternal and child death, TB deaths, Malaria deaths are recorded and analyzed properly.
    There are hardly and epidemiologists and demographers in the health departments
  • 18. Neglect of water / sanitation…… nutrition
    Neglect of social determinants of health
    Hygiene & infection control / Asepsis poor
    Over use of antibiotics….
  • 19. How do we move forward??
    Tripling the health public expenditure on health
    Making it simple to spend money
    Make outcome accountability – mortality & morbidity reduction – not just coverage
    “people pleasing services”
    Better HR management – people produce health services -
  • 20. Set standards and measure quality
    Reward performance and quality
    Do not run after targets, numbers and quick successes…
  • 21. Silver lining???
    NRHM – increasing resources, TA, managerial staff.. Flexibility….
    PPP – Cataract surgery, chiranjeevi scheme, other programs
    HR discussions – augmentation – ASAH, contract docs and specialsits
    Task shifting/sharing – Nurse-midwife, MO – CEmOC, NN care trg…
    Health insurance through RSBY, Arogyashree in AP…
    Vibrant NGO….
    New institutions – focus on Public Health
  • 22. Can we make a desert like heath system to a blooming garden ?