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Kerala Perspective Plan2030-Health Sector Analysis
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Kerala Perspective Plan2030-Health Sector Analysis

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An analysis of the KPP 2030 with special reference to Health sector..

An analysis of the KPP 2030 with special reference to Health sector..

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    • 1. Dr. Manju S.Nair
    • 2.  The KPP 2030 is a GoK initiative that will serve as the basis for implementation of a series of initiatives aimed at fostering sustainable and inclusive growth of the economy.  Outcome based strategic planning  Identifies development challenges and outlines high quality planning to achieve the goals  Situation analysis, vision, mission, goals, strategies
    • 3.  Situation analysis- summary of Kerala‟s achievements  Then identifies the major health challenges as  1. Health Status  2. Health Infrastructure  3. Health Financing
    • 4.  Health indicators not on par with developed nations  Increasing incidence of communicable and non communicable diseases  Gender issues  Ageing and age related health issues
    • 5.  Inadequate infrastructure in terms of hospital, beds, doctors and nurses  Declining primary health centres and community health centres
    • 6.  Increasing out of pocket expenditure  Increasing per capita health expenditure  Health expenditure as percentage of GSDP
    • 7. „Kerala will ensure “health for all” by 2030.  It will provide health security provision to each and everyone by 2030.  It will have a highly innovative, affordable, and accessible health system that all Keralites can trust.  It will have a health system that is accessible when people need it, regardless of their ability to pay.  Kerala would also be able to establish in the global health care services market generating foreign exchange and driving its growth process 
    • 8. Good health and well being for all Keralites throughout their lives  Timely and equitable access for all Keralites to a comprehensive range of health and disability services, regardless of their ability to pay  A high performing system in which people have confidence  Active involvement of consumers and communities  Transformation of the health sector into a growth driving sector by positioning it in the international health care services market. 
    • 9.  1. Health for all  Increase the health expenditure to GSDP ratio from 0.6 per cent in 2012 to 4-5 per cent by 2030. This will be achieved by one per cent point increase spread over the next five year plans  Reduce MMR from 81 to 12 per lakh live births  Reduce IMR from 13 to 6 per 1000 live births  Eradicate communicable diseases  Prioritise health areas to include mental diseases, alcoholism and suicides
    • 10.  Increase the number of hospital beds from 34 per 10,000 in 2004 to 70 by 2030  Increase the number of nurses from 12.4 in 2004 to 65 by 2030.  Increase the number of doctors from 9.9 per 10,000 population to 17 in 2030.  Provide health insurance cover to all  2. Promote health hubs  Set up three medical cities by 2030.
    • 11.  Four pillars  1. Economic prosperity through health  2. Enhance human capital by promoting world class facilities  3. Social health  4. Natural and environmental capital
    • 12.  1. create global health cities  2. international bench marking  3. promote Research and Development  Medical tourism, FDI, MNCS  Will it create a health system that is accessible when people need it, regardless of their ability to pay.
    • 13.  Promote health education students from other countries will be attracted to the cities promoting medical services
    • 14.  1. health promotion through self care and community participation  2. strengthen health care services – should be inclusive in nature, for that public –private partnership in ensuring quality health care services.  Health care services in public health care facilities may be franchised to private players.  Performance linked compensation to health workers in specific government run programme
    • 15.  3. alternative systems of medicine  4. facilitate health financing – a small write up on RSBY and a small note on Health Voucher Scheme for the poor  5. increase public investment in health sector – mere lip service
    • 16.  The strategy for Hospital Common Waste (HWC) management will require a „Bio Medical Waste Management Legislation‟, supervised together by the state Department of Health and Department of Environment. This legislation will be comprehensive with detailed policies on  Facilities and procedures, labelling, treatment, transport, inspections. Fees etc.
    • 17.  If the vision is health for all  Strategy will be an utter failure  It will wipe out all the health achievements that Kerala has earned throughout its plan process  Doesn‟t take into consideration any of the ground realities  Just to convert health system into a corporate system  Leaving the importance of public health system – only curative that too expensive and not preventive
    • 18.  Health care will become inappropriate to the vast majority of the Keralites, not only for the poor but for the rich also  Out of pocket expenditure and catastrophic health expenditure.  Health care induced poverty will be the major type of poverty in Kerala by 2030.  „good health at low cost‟ will be converted to „bad health at exorbitant cost‟
    • 19.  Kerala has achieved commendable progress in health – CDR, IMR, LE  Kerala model – „good health at low cost‟  It was possible at low level of resources to achieve laudable health status, at least by measures of mortality and gross morbidity  Kerala became a model for the right kind of social policies – which would ensure balanced and equitable development and steady improvement in health indices
    • 20.  This health development generally attributed to  spread of education, especially female education,  political awareness  development of road networks and transportation  social movements
    • 21.  Historical factors  struggle for social reforms  agrarian reforms  Improvement in the social living conditions of the landless poor in the rural areas  public distribution system.  At the time of formation of the present Kerala state on 1 November, 1956, the foundation for a medical system accessible to all citizens were already laid  the proportion of government expenditure set apart for health.
    • 22.  government health expenditure -13.04 percent  government expenditure - 12.45 percent  state domestic product at 9.81 percent.  From 1961 to 1986, the state generally expanded its government health facilities.  The number of beds and institutions increased sharply.  The total number of beds in government hospitals in the western medical sector increased from around 13,000 in 1960-61 to 20,000 in 1970-71, and 29,000 in 1980-81.
    • 23.  By 2000 – increasing burden of diseases  Mediflation  Now, Kerala‟s health care dependent on one‟s ability to pay, though with no assurance to quality  This is against a model which was once characterised by health security, whatever one‟s socio economic position, the state used to provide health care
    • 24.  The state, which set an example for the rest of India and third world countries in providing primary health care, now gropes in the dark and is fast losing the edge  The great achievements in the field of mortality and fertility have reached a plateau and the morbidity rates and increasing.  It can no more be called as „good health at low cost‟  Kerala on the brink of a public health crisis
    • 25.  epidemiologic transition  Kerala is now passing through the third stage of epidemiological transition  Life style diseases  But, some communicable diseases have reemerged and some new epidemics have emerged in the state.
    • 26. Waterborne diseases  diarrhoea (per 10,000) increased from 14.14 percent in 2011 to 19.76 in 2012.  Leptospirosis - 7.4 and 2.2 percent of the total people infected had succumbed to death in 2011 and 2012 respectively.  Vector Borne diseases  Dengue fever,  Malaria,  Chikungunia,  H1N1 and Japanese Encephalitis are still remaining as seasonal threats. 
    • 27. Disease 2007 2008 2009 2010 2011 Malaria 1927 1804 20466 2199 2334 Dengue 677 733 1425 2597 1304 Chickungunia 24052 24685 13349 1531 1708 Hepatitis A 5350 6963 7844 5181 5122 Leptospirosis 1359 1305 1237 1016 976 1578 1534 567 H1N1 fever
    • 28.  HIV epidemic in Kerala is distinctly related to migration.  HIV prevalence rate in the general population is 0.26.  The estimated number of people infected with HIV in Kerala is 55167. A total of 10846 cases and 1719 deaths were reported in 2011
    • 29. Kerala is witnessing a rising incidence of non-communicable diseases and old age diseases.  In the age group between 30 and 60, more than 50 per cent of death occurs as a result of NCDs.  These include diseases such as heart disease, stroke, high blood pressure, cancer and stroke. 
    • 30.  on an average 110 individuals are dying of cardiovascular diseases daily in the state.  Cardiovascular diseases results in 50 percent of total deaths in the state.  It is expected that by 2020, the death tally in the state as a result of cardiological complaints will increase to two third.  Kerala has the highest prevalence of coronary artery diseases in India. Prevalence rate of coronary artery diseases is 7.5 in rural areas and 12 percent in urban areas.
    • 31. 52.1 percent of males and 61.4 percent of females in Kerala have a cholesterol level greater than 200 milligrams per decilitre (mg/dl).  Kerala has the highest number of diabetic cases in India with 27 percent of the males and 19 percent of the females  One out of every three individuals in Kerala has hypertension.  Diseases like diabetes and cancer had increased the level of mental stress in the state which resulted in the prevalence of hypertension in Kerala. 
    • 32.  Cancer shows an ever increasing trend in recent years.  more than 35,000 thousand new cases of cancer are reported annually.  Around one lakh patients are under treatment every year in various hospitals  The prevalence rate of chronic respiratory illness increased in 2012 to 305.12 per ten thousand from 233.88 in 2011.
    • 33.  As per State Crime Records Bureau (2012), a total of 35216 accidents occurred in the state in 2011, which resulted in the death of 4,145 individuals.  25,110 were seriously wounded  another 16,269 suffered from minor injuries
    • 34.  Recent studies of Kerala State Mental Health Authority show that 4.5 lakh people in Kerala have mental illness like schizophrenia, mood disorder, profound mental retardation and severe personality problems.  Social stigmatization of mental patients is also a problem faced by the health care sector in the state.  Suicide rate in Kerala is increasing at an alarming rate. 0.4 to 0.9% of all deaths in the hospitals and 0.3 to 1% all casualty admissions are following suicidal attempt (KSMHA, 2009).
    • 35.  The suicide rate in Kerala in 2011 is 25.3 per lakh with an aggregate registered case of 8431.  Alcohol and drug related health problems are very high in the state.  In the year 2012-13, the overall sales touched an all time high.  With regard to per capita liquor consumption, Kerala is at third position in India after Maharashtra and Punjab.  Divorce rate in Kerala is much higher than other states in India.  In the year 2012, a total of 16,917 divorce cases in the state.
    • 36.  The proportion of aged in total population had increased from 5.8 percent in 1961 to 10.8 (10 percent of male and 11.62 percent of females in total population).  As per the projected figures, by the year 2021, the proportion of aged people in the population will reach 16 percent and by 2051, the same will reach 30 percent.
    • 37.  Among all age groups, the fastest growing group is the old old (66-79 years). The oldest old (80 and above) also shows an increasing trend.  The dependency rate of elderly people in Kerala is also showing an increasing trend in recent years  16 percent of the elderly folk are supported by 42.2 percent of the working age population
    • 38.  Leaving the whole sort of issues to be tackled by the MNC aided global health cities  ?????????????????????????????????????????????????????
    • 39. Plan period State’s total outlay Outlay on % of health health outlay on total outlay First plan 3003.00 192.00 6.39 Second plan 8700.71 874.74 9.74 Third plan 17000.00 1340.00 7.94 Annual plans 14437.00 495.00 3.43 Forth plan 25840.00 1044.00 4.04 Fifth plan 56890.00 1249.00 2.19 Annual plans 42870.00 903.00 2.11 Sixth plan 155040.00 3595.60 2.32 Seventh plan 210000.00 5050.00 2.40 Annual plan 66020.00 1700.00 2.57 Annual plan 77500.00 1955.00 2.52 Eighth plan 546000.00 12000.00 2.20 Ninth plan 1610000.00 30940.00 3.06 Tenth plan 2400000.00 40840.00 2.60 Eleventh plan 4042200.00 96569.00 2.39
    • 40. State Percentage of public Percentage of Percentage of private public private expenditure Himachal Percentage of State expenditure expenditure expenditure 37.8 62.2 Gujarat 18.0 82.0 30.9 69.1 Andhra 17.5 82.5 Pradesh Assam Pradesh Rajastan 30.4 69.6 Punjab 16.8 83.2 Karnataka 28.9 71.1 Madhya 15.2 84.8 Pradesh Jammu & 25.5 74.5 Kerala 12.9 87.1 Tamil Nadu 23.9 76.1 Bihar 11.8 88.2 West Bengal 23.4 76.6 Haryana 10.4 89.6 Orissa 23.0 77.0 Utter Pradesh 7.5 92.5 Maharashtra 19.4 80.6 Kashmir
    • 41.  Private hospitals now surpass government facilities in the density of beds and employment of personnel.  More significantly, private hospitals have far outpaced government facilities in the provision of hi tech methods of diagnosis and therapy, such as computerized tomography (CT) scans, endoscopy units, magnetic resonance imaging (MRI), neonatal care units, coronary units etc.
    • 42.  factors outside the health sector could have facilitated the growth in the private sector.  rising disposable incomes  lack of barriers to opening a private hospital.  the ageing of the population.  reflected in the higher proportion of chronic diseases among them and their higher spending on health care.
    • 43.  According to KSSP‟s study, on an average, in Kerala, a person spends almost Rs. 6,000 an year out of his own pocket to seek medical care.  This is four times the amount that a person used to spend from his pocket on health six years ago.  (KSSP‟s similar study in 2004 put the average own expense on health at Rs. 1,500).
    • 44.  When this figure - Rs. 6,000 – is projected against the State‟s total population, the people in Kerala are spending a mammoth Rs. 19,000 cr. plus annually from their own pockets for health care.  This is apart from what the Government is currently spending on health care
    • 45. The average annual out-of-pocket spending by a person with chronic illnesses was about Rs. 38,000.  The average out-of-pocket expenditure of a person in visiting OP (out-patient) clinics in the Government sector was Rs. 4,034 in an year. In the private sector, this OP expense was not very different at Rs. 4,739.  However, when it came to IP expenditure (inpatient), the average annual out-of-pocket expenditure was Rs. 6,267 against the figure of Rs. 30,800 in the private sector. Here again, this escalation in expenditure was mostly due to the involvement of expensive corporate hospitals. 
    • 46. According to the National Family Health Survey India - 3 (NFHS – 3), with regard to Kerala:  56.1% children aged between 6-35 months are anemic  32.7 % ever-married women aged between 15-49 are anemic  33.8% pregnant women aged between 15-49 are anemic.  Infant mortality is estimated at 15 deaths before the age of one year per 1,000 
    • 47.  Under-five mortality is 16 deaths per 1,000.  Perinatal mortality, which includes stillbirths and very early infant deaths (in  the first week of life), is estimated at 11 deaths per 1,000 pregnancies  Perinatal mortality in rural areas, at 15, is much higher than the rate in urban areas.
    • 48.  As per the Audit Report (General and Social Sector) for the year ended 21March 2013, the percentage of malnourished children below the age of six years in the State ranged between 27 and 39.  Test check of records in Idukki, Malappuram, Palakkad and Thiruvananthapuram districts indicated that 110 out of 1180 children who died during 2011-12, were severely malnourished. the number of severely malnourished children in Palakkad was 4,633
    • 49. the Auditor General in its report on ICDS  The percentage of child population who were not immunized against Polio and DPT in Palakkad and Malappuram districts were respectively 36 and 31.  The objective of universalization of Supplementary Nutrition Programme was not achieved as 56 to 66 per cent of the identified beneficiaries were not covered under the Scheme. 
    • 50.  While the `Kerala Development Model‟ gained national and international appreciation as an adaptable development ideal, the experiences of the marginalized of Kerala was entirely excluded from the much acclaimed statistical information and academic studies.  Human Development Report 2005, which while discussing horizontal inequalities that persist in Kerala among Dalits, Adivasis and fishing communities, pointed out that:
    • 51.  “….There is no denying one’s location within the network of social affiliation substantially affects one’s access to resources…”.  Tellingly, NFHS-3 states that the infant mortality rate changes sharply with household wealth and is higher for women who belong to other backward classes.
    • 52.  The continuing deaths of children in the Attappady Hills, Palakkad district in Kerala has shocked the conscience of the entire country  The death of even one child due to malnutrition is a tragedy  this constitute a serious human rights violation and a breach of constitutional obligations
    • 53.  If the state withdraws from the scene or goes for a public private partnership  ??????????????????????????????????????????????????????
    • 54. A society that is healthy  Should meet the twin challenges of reemerging and emerging diseases  Provide an environment that is conducive to healthy life  That can afford and willing to meet the cost of health care  Take care of the old and weak  Regulate the unethical practices
    • 55.  Clean drinking water  Sanitation facilities  Solid waste management  Poverty  Enforcement of regulation for good health – food safety act and public health act
    • 56.  Linking the institutions in a networked care system  higher level of organisation and management  Revamping the primary care provider institutions, Community health centres, Taluk Head Quarters Hospital, District Hospitals and Medical College Hospitals
    • 57.  Equipped to meet the new challenges –NCDs, Mental health, geriatric care  Population per SC – 5000 to be changed to 3000 or go for a four tier system  Or the SC and PHC should be enlarged  PHC should have standard design with patient waiting areas, separate and clean toilets, safe drinking water, examination room that respect the privacy of patients and a lab that offers all routine investigation  More medical officers
    • 58.  Must be the source of specialist treatment. CHC should have facilities in pediatrics, general surgery, gynecology, obstetrics and general medicine  Facilities at the CHC would be utilized as a coordinating centre of pain and palliative care, terminal care and community mental health programme
    • 59.  In addition to major specialities, other specialities such as ortho, ENT, dentistry, dermatology, psychiatry, ophthalmology  Blood bank facilities and second level lab facilities should be provided  First level trauma management
    • 60.  To be upgraded in view of the increasing prevalence of NCDs and the challenge of managing co-morbidites  Dialysis, cardiac care, cancer care, neurological cases should be provided  Advanced laboratory facilities including CT scan should be provided  Doctors being offered PG and super specialty seats under government quota in Medical College should be earmarked for posting in district hospitals
    • 61.  Ayurveda  Homeo  Medical College hospitals – quality and research.
    • 62.  Systems to be devised to ensure that person educated through public resources are available to serve the public should the need arise  The state can provide manpower for export or to meet the needs of private providers with government effectively discharging the regulation functions  Need for clinical specialty and super specialty seats in view of increasing demand for tertiary care
    • 63.  New courses are needed in geriatric, emergency and critical care and family medicine, M.Ed courses which enables specialty practices  Continuing medical education
    • 64.  Develop and improve systems to ensure governance of the health system  A) establish a public health cadre  B) improve regulatory environment  C) system of multi sectoral collaboration  D) addressing the special needs of special population  E) ensure quality of drugs and make them affordable  F) improve regulatory environment
    • 65.  1. control and management of communicable diseases promotion of good health and prevention building a cadre of public health leaders levels of vaccination should be high enough to ensure vaccine preventable diseases based on seasonality and epidemiology the state should take advanced action to prevent the spread of diseases need for formalising and strengthening structures such as the ward level health and sanitation committees and health standing committees of LSGs
    • 66.  2. Prevention and management of lifestyle related diseases. a holistic approach leading from preventive action for the healthy, screening for the high risk population, primary care for the affected, tertiary for the acute cases and palliative care for the terminally ill patients  Prevention of accidents, trauma care  Reduction of IMR, MMR etc  Mental Health  Health of the aged and palliative care
    • 67.  Thus if the KPP is aimed at fostering sustainable and inclusive growth of the economy the strategies visualised in the Perspective Plan 2030 will totally derail the whole system.
    • 68.  To be inclusive  Growth must carry the many with it  Secondly, it must satisfy the widest range of our material needs  It must address the binding constraints  And the question of distribution - ie Are the emerging opportunities being distributed equally
    • 69.  Growth does raise household incomes and helps to remove poverty, especially if health, education and other basic capabilities that enable people to participate in the growth process are widely shared  If KPP is followed Keralites will become the most ill healthy population in the world  There is a strong case for forceful public demand for much larger allocations to basic public services like health
    • 70.  The constructive use of public resources generated by economic growth to enhance human capabilities contributes not only to the quality of life but also to higher productivity and further growth

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