2. Health Systems: An Overview
โข Indian health sector has evolved both in terms of quantity and quality
overtime. This sector has a vital role in both the wellbeing of the
community and the development of the country.
โข India has made significant progress, not only in health infrastructure
and resources but also in various health indicators. However, India
faces serious challenges in the implementation of policy intentions
and strategies.
โข There are gross inequitable in access and availability of health
services, especially for poor and disadvantaged section of society.
Despite a vast network of public-sector healthcare institutions, a large
health workforce and resource mobilization, almost 70 % people use a
private health facility for outpatient care.
3. Health Systems: An Overviewโฆ
โข Andhra Pradesh is one of the most progressive states in India and has
achieved its demographic goal with a TFR of 1.8 (< 2.1).
โข It has some significant achievements in improving key health
indicators โ infant mortality rate (35 per 1000 live births), maternal
mortality ratio (92 per 100,000 live births), which are much below the
national average. The coverage with full immunization among children
aged 12-23 months is slightly higher than the national average, at
65.3% compared to 62%. About 40% of the pregnant women received
full ANC and 76.3% received at least 4 ANC visits.
4. โข However, the state of nutrition among women and children was a
concern, as 52.9% of pregnant women and 58.6% of children were
reported to be anemic. Malnutrition among children under five was
high, with 31.4% found to be stunted, 31.9% underweight, 17.2%
wasted and 4.5% severely wasted (NFHS 4, 2015). Still, a lot needs to
be done to achieve SDG targets in the next 12 years.
5. Key Indicators: Current Status
Indicator Current Status
(2013-15)*
SDG Target
(2030)#
Maternal Mortality Ratio
(per 100,000 live births)
92 < 70
Infant Mortality Rate
(per 1000 live births)
35 < 12
Under-five Mortality Rate
(per 1000 live births)
41 < 25
Source: *Niti Aayog, *NFHS 4, #UN India 2016
6. Identifying and prioritizing Health System interventions in
Andhra Pradesh for Cost-Benefit Studies
โข A sector expert consultation on Health was held on 25th Oct 2017 in Vijayawada.
A total of 27 experts participated in the consultation. The stakeholder
consultation was organized to identify and prioritize the health system
interventions in Andhra Pradesh for cost-benefit studies. The stakeholder
consultation was attended by officials from Government of Andhra Pradesh,
development partners, NGOs, academic and research institutions. In all, 29
interventions were identified for strengthening health systems. Out of 29, the
following 3 interventions were prioritized for cost-benefit analysis:
1. Strengthening emergency obstetric and newborn care to reduce Maternal
and Neonatal deaths
2. Improved emergency referral management by 108 ambulance services
3. Family planning services
7. Data Sources
Following data sources were used in this analysis:
- Global Burden of Disease, 2016
- Census, 2011
- NFHS 4, 2015
- Niti Aayog data
- Apart from these, data were also collected from unpublished government
documents, interviews of government officials, and published papers.
8. Strengthening basic and emergency obstetric
and newborn care for reducing maternal and
neonatal deaths
Solution 1
9. Problem
โข Most recent data on key health indicators of the state of Andhra
Pradesh such as โ infant mortality rate (35 per 1000 live births),
maternal mortality ratio (92 per 100,000 live births) and under-five
mortality rate (41 per 1000 live births) suggest that the state is far
behind the targets set in the Sustainable Development Goals (SDGs).
โข Complications during pregnancy and childbirth cause 800 maternal
deaths and 12,100 neonatal deaths per year in Andhra Pradesh.
Andhra Pradesh has relatively better indicators than other states, but
still requires significant effort to achieve related SDG targets.
10. Problemโฆ
โข In Andhra Pradesh, the female population forms virtually half of the
15-49 years age group. This population group experiences enormous
suffering due to the unequal distribution of maternal and child health
services. NFHS 4 report shows that 60% of females among the
reproductive age group (15-49 years) are anemic in Andhra Pradesh.
โข The State has relatively better indicators compared to other states,
but it still requires significant effort to achieve related SDG targets.
Coverage of basic and emergency obstetric care is critical factor to
improve the quality of care for mothers and newborn in Andhra
Pradesh.
11. Solution
โข The key focus was on reducing maternal mortality by strengthening
the service quality of maternal health intervention. Basic Emergency
Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric
Care (CEmOC) have been extensively promoted to improve maternal
and neonatal health outcomes. However, the consensus about
universal access to high-quality BEmOC and CEmOC services is facing
challenges duet to uncertainties about how best to implement them
in specific situations (MOHFW/GOI, 2007).
โข It is essential to ensure an adequate number of skilled staff, efficient
support system, and well equipped facilities for CEmOC to overcome
barriers to maternal care predominantly in rural areas. In this study,
we focus on a couple of interventions which collectively play their
roles in reducing the maternal mortality ration. The intervention will
work in a prospective manner initially for 20 years.
12. Costs
โข The cost includes investments in physical and human infrastructure
(building, renovation, equipping medical facilities, training and
retaining staff, improving the referral and medical supply system) as
well as demand generation, outreach, supervision, monitoring and
evaluation activities.
โข The total cost of the intervention is estimated as INR 3028 crores at a
5% (annual) discount rate.
13. Benefits
โข These interventions are estimated to result in a reduction of maternal
mortality by 40%, saving 319 maternal lives per year. They will also
reduce neonatal mortality by 8%, saving 1019 newborn lives per year.
โข The estimated benefit due to this intervention is INR 22,107 crores at
5% discount rates.
14. BCR
โข The total cost of the intervention is estimated as INR 3028 crores and
the total economic benefit of saving the maternal and neonatal lives is
expected to be INR 22107 crores at 5% discount rate.
โข Using these assumptions, the Benefit-Cost Ratio (BCR) is 7.3 for this
intervention.
16. Problem
โข Ambulance services constitute a critical component of Emergency
Medical Services (EMS) to transport patients to health facilities on
time, which is essential to ensure timely and adequate care.
โข In Andhra Pradesh, there is a shortage of ambulances, which results in
an unintended delay in timely health service delivery. The suggested
number of ambulances is 33 per 1 million people in urban areas and
about 3 times higher in rural areas.
17. Problemโฆ
โข As per NFHS-4, only 24% of the pregnant women were transported by
ambulance services in India. The situation in AP was even poorer, with
a coverage of only about 14%.
โข In Andhra Pradesh, currently 468 ambulances are providing services,
of which 42% are deployed in urban areas.
18. Solution
โข The intervention considers deployment of additional ambulances,
which are expected to remain operational for the next 10 years. The
indicators to measure the improvement in population health will be
the coverage of the ambulances services.
19. Costs
โข In this intervention, we calculated both the capital and recurrent
costs. The capital cost is a one-time investment for the next 10 years.
In addition, there will be recurrent annual costs such as salaries,
operations and maintenance, training, etc. It is estimated that the
total number of ambulances required as 33 per million population in
the urban area and 99 per million population in the rural areas.
โข Hence, the total cost to fulfil the need for ambulances in urban and
rural areas of the state comes to INR 999 crores and INR 7950 crores,
respectively.
20. Benefits
โข For estimation of benefits, the data for referrals for ischemic heart
diseases, road traffic accidents, and obstructed labour cases were
used. A total of 4236 and 12,076 deaths in urban and rural areas are
avoided and 48,731 and 138, 541 DALYs averted at 5% discount rates
in urban and rural areas respectively.
โข The total benefit in economic terms would be INR 16,837 crores in
urban areas and INR 47,867 crores in rural areas.
23. Problem
โข In 1952, India launched the worldโs first National Programme for
Family Planning. This initiatives gradually led to the National
population Policy in 2000 to reduce fertility rates. Globally, the
prevalence of unmet need for contraception is still high.
โข The NPP 2000 was adopted to achieve a TFR of 2.1 by 2010 from 2.7
of 2005/06. However, in 2017, it is still about 2.3, although in 17
states the TFR has reached below 2.1. And AP is among them, with a
TFR of 1.8. Along with this, the total unmet need for contraception
stands at 4.7% (NFHS โ 4, 2015) and this indicates there is a demand
for family planning measures as well.
24. Solution
โข The intervention looked forward over the next 50 years, as our
ultimate target is to reduce the number of unwanted children and
decrease the prevalence of unwanted pregnancy related abortion.
25. Costs
โข The cost of the intervention includes the cost of service delivery and
procurement of contraceptives for the target population. The total per
capita cost is about INR 386 at 5 % annual discount rate.
26. Benefits
โข Providing family planning services could avert an estimated 1174 and
69 deaths respectively for child and mother annually, as well as
additional benefits arising from reducing population growth rate.
โข Major benefit would come by way of demographic dividends but the
child and maternal lives saved due to family planning methods would
also be important. The total economic benefits would be about INR
6,310 per capita years at 5% discount rate, which his 16 times of the
investment costs.
27. BCR
โข The benefit cost ratio for family planning intervention is 16.3 at 5%
discount rate.
28. Solutions: BCR Summary
Interventions BCR Total Benefit
(INR crore)
Total Cost
(INR crore)
Maternal and Child Health 7.3 22,107 3,028
Ambulance (Urban) 16.8 16,837 999
Ambulance (Rural) 6.0 47.837 7,950
Family Planning (per capita-years) 16.3 6,310 386
29. Conclusion
โข Our estimations show that enhanced investment on selected health
interventions improves access, coverage, outcomes, and impact.
โข By scaling up the surgical capacity will provide an estimated BCR of 7.3
at 5 % discount rate.
โข The BCR in ambulance service intervention will be 16.8 for urban area
and 6 for rural area at 5 % discount rate.
โข The BCR in family planning (per capita-years) will be 16.3 at 5%
discount rate.
โข So, among these three interventions largest return could be achieved
on an investment in emergency ambulance service (Urban) followed
by the family planning services, and surgical capacity intervention.
โข Since the interventions target different population groups, the
findings of the study suggests complementary to each other rather
than competitive.
