Rajasthan priorities health systems, iihmr

1. Health Systems

2. Health Systems: An Overview
• Indian health sector has evolved both in terns of quantity and quality
overtime. This sector has a vital role in both the wellbeing of the
community and the development of the country.
• India has made significant progress, not only in health infrastructure
and resources but also in various health indicators.
• Rajasthan is second largest in land area and represents 5.67% of
country’s population.
• There are gross inequitable in access and availability of health
services, especially for poor and disadvantaged section of society in
the state of Rajasthan.

3. Health Systems: An Overview…
• Rajasthan belongs to a group designated as high Focus States under
NRHM. The State’s health indicators – infant mortality rate (41 per
1000 live births), maternal mortality ration (244 per 100,000 live
births) and total fertility rate (2.4 children per woman) are poor.
• About one-third of the population of the state belongs to SC/ST, which
traditionally have lower health indicators.
• Also, the western Rajasthan is desert, which has a low population
density. This makes healthcare delivery quite challenging task in this
part of the state.

4. Key Indicators: Current Status
Indicator Current Status
(2013-15)*
SDG Target
(2030)#
Maternal Mortality Ratio
(per 100,000 live births)
244 < 70
Infant Mortality Rate
(per 1000 live births)
41 < 12
Under-five Mortality Rate
(per 1000 live births)
51 < 25
Source: *Niti Aayog, *NFHS 4, #UN India 2016

5. Identifying and prioritizing Health System interventions in
Rajasthan for Cost-Benefit Studies
• A stakeholder consultation was organized to identify and prioritize the health
system interventions in Rajasthan for cost-benefit studies. The stakeholder
consultation was attended by officials from Government of Rajasthan,
development partners, NGOs, academic and research institutions. In all, 24
interventions were identified for strengthening health systems. Out of 24, 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

6. 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- Apart from these, data were also collected from unpublished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.

7. Strengthening emergency obstetric and
newborn care to reduce Maternal and
Neonatal deaths
Solution 1

8. Problem
• Most recent data on key health indicators of the state of Rajasthan
such as – infant mortality rate (41 per 1000 live births), maternal
mortality ration (244 per 100,000 live births) and under-five mortality
rate (51 per 1000 live births) suggest that the state is far behind the
targets set in the sustainable Development goals (SDGs).
• Complications during pregnancy and childbirth cause 4267 maternal
deaths and almost 30,000 neonatal deaths per year in Rajasthan.
Coverage of all four ANCs was 38.5% in the state (NFHS 4).

9. Problem…
• The maternal and child health indicators in Rajasthan are lower than
national average; hence the state needs to redesign its interventions
to accelerate improvement in these indicators.
• Achieving the SDG targets on maternal and child health will require
significant effort.
• In this context, we are looking at improving the coverage of basic and
emergency surgical capacities to provide better care for mothers and
newborn in Rajasthan for reducing maternal and neonatal deaths.

10. Solution
• The intervention will work in a prospective manner initially for 20
years. The benefits will be same for next 19 years as in the first year as
per the assumptions.
• The goal of this intervention is a decrease of 66% in the maternal
mortality rate compared to the pre-intervention status.

11. Costs
• 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.
• The total cost of the intervention is estimated as INR 11, 495 crores at
a 5% (annual) discount rate.

12. Benefits
• These interventions are estimated to result in a reduction of maternal
mortality by 66%, saving 2827 maternal lives per year. They would
also reduce neonatal mortality by 20%, saving 6542 newborn lives per
year. By reducing these deaths 136, 473 DALYs per year could be
averted at 5% discount rate.
• Total benefits of the intervention are estimated at INR 111, 563 crore
at 5% discount rates.

13. BCR
• The total cost of the intervention is estimated as INR 11, 495 crores
and the total economic benefit of saving the maternal and neonatal
lives is expected to be INR 111, 563 crores at 5% discount rate.
• Using these assumptions, the Benefit-Cost Ratio (BCR) of this
intervention would be 9.7

14. BCR of strengthening emergency obstetric and newborn care to
reduce Maternal and Neonatal deaths
Discount rate
3% 5% 8%
Benefits (INR) 197,788 111,563 56,725
Cost (INR) 13,460 11,494 9,314
BCR 14.7 9.7 6.1
*All cost and benefits are in Crores of INR

15. Improved emergency referral management by 108
ambulance services
Solution 2

16. Problem
• Ambulance services constitute a critical component of Emergency
Medical Services (EMS) by transporting patients to health facilities
quickly, which is essential to ensure timely and adequate care. The
system has been ineffective due to poor availability of vehicles, poor
infrastructure, the lack of trained pre-hospital personnel, and a lack of
access to services.
• In Rajasthan, 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. Problem…
• In Rajasthan, currently 741 ambulances (which is about 12% of
estimated number of ambulances against recommended numbers)
are providing services of which 42% are deployed in urban areas. As
per NFHS 4, only 14.5% of pregnant women were transported.

18. Solution
• 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
• The capital cost is a on-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.
• Hence, the total cost to fulfil the need for ambulances in urban and
rural areas of the state comes to INR 1,093 crores and INR 12,076
crores, respectively.

20. Cost part
Cost Head Urban Rural
Capital cost 75.34 1027.63
Operational expenditure 58.76 801.55
Training costs 0.57 4.70
Salary cost 66.14 5,56.44
Total Cost 200.81 2390.32
Net present Value (10 Years) at 5 %
discount rate 1,092.75 12,076.28
• An estimated number of required ambulances:
•Urban Area- 377; Rural Area- 5138
*All cost in Crores of INR

21. Benefits
• For estimation of benefits the data for referrals for ischemic heart
diseases, road traffic accidents, and obstructed labour cases were
used. A total of 3047 and 12,637 deaths in urban and rural areas are
avoided and 36, 967 and 152, 397 DALYs averted at 5% discount rates
in urban and rural areas respectively.
• The total benefit in economic terms would be INR 9,645 crores in
urban areas and INR 39,762 crores in rural areas.

22. BCR
• The benefit cost ratio for urban is 8.8 and for rural is 3.3.

23. BCR of improved emergency referral management by 108
ambulance services
Urban
Ambulance
Discount rate
3% 5% 8%
Benefits (INR) 13,399 9,645 6,342
Cost (INR) 1,177 1,092 984
BCR 11.4 8.8 6.4
Rural Ambulance
Discount rate
3% 5% 8%
Benefits (INR) 55,141 39,762 26,192
Cost (INR) 13,000 12,076 10,903
BCR 4.2 3.3 2.4
*All cost and benefits are in Crores of INR

24. Family Planning
Solution 3

25. Problem
• In 1952, India launched the world’s first National Programme for
Family Planning. This initiatives gradually led to the National
population Policy in 2000 to achieve a total fertility rate (TFR) of 2.1
by 2010. However, in 2017, it is still about 2.3, although in 17 states
the TFR has reached below 2.1 and Rajasthan, the TFR is currently at
a higher level (2.4), which calls for a focus on it.
• Along with this, the total unmet need for contraception stands at
12.3 % (NFHS 4).

26. Solution
• 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.

27. Costs
• 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 614 at 5 % annual discount rate.

28. HEADS COSTS (INR)
Cost of delivering Family Planning services for
one year, per person 1,210
Cost of implementation 19.24
Target population* 2,273,188
Net Present Value of per capita cost at 5%
discount rate for next 50 years 614
Cost part
*Women with unmet need among child bearing age group population;

29. Benefits
• 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.
• 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 per capita economic benefits would be
about INR 19728.

30. • The demographic
dividend represents
85% of the
undiscounted benefits
from the intervention.
• Lives saved 1117
children and 69
Women.
• Net present value of
per capita benefits is
INR 19,728 at 5%
discount rate.
Benefits
0
10000
20000
30000
40000
50000
60000
70000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49
Proportion of demographic and health
benefits by Family Planning
DEMOGRAPHIC DIVIDEND BENEFIT HEALTH BENEFIT

31. BCR
• The benefit cost ratio for family planning intervention is 32 at 5%
discount rate.

32. BCR of family planning intervention
Discount rate
3% 5% 8%
Benefits (INR) 40081 19728 8007
Per Capita Cost (INR) 859 614 416
BCR 47 32 19

33. Conclusion
• Our estimations show that enhanced investment on selected health
interventions improves access, coverage, outcomes, and impact.
• By scaling up the surgical capacity will provide an estimated BCR of 9.7
at 5 % discount rate.
• The BCR in ambulance service intervention will be 8.8 for urban area
and 3.3 for rural area at 5 % discount rate.
• The BCR in family planning services will be 32 at 5% discount rate.
• So, among these three interventions largest return could be achieved
on an investment in family planning services, followed by the
emergency ambulance service, and surgical capacity intervention.
• Since the interventions target different population groups, the
findings of the study suggests complementary to each other rather
than competitive.

34. Thanks