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Health system by- Dileep Mavalankar

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Health system by- Dileep Mavalankar

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

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