This article deals with ‘ Issues relating to development and management of Social Sector/Services relating to Health .’ This is part of our series on ‘Governance’ which is important pillar of GS-2 syllabus . For more articles , you can click here
Primary , Secondary and Tertiary Sector
1 . Primary Healthcare
- Denotes first level of contact between individuals & with health system
- Includes family planning , immunization, treatment of common diseases , health education etc
- In India , Provided through network of
- Primary Health Centres in Rural Areas
- Family Welfare Centres in Urban Areas
2. Secondary Healthcare
- Second Tier of Health System
- District Hospitals
- Community Health Centre (CHC) at Block Level.
3. Tertiary Healthcare
- Third Level of Health Care
- Provide specialised consultative care
- Provided by Medical Colleges & Medical Research Institutes
- India spends a total of 4 per cent of its GDP on health, which in itself is a
significant amount. However, it is high
out-of pocket expenditure that cause problem
- Total Spending on Health = 4% of GDP
- Public Sector = 1.15% of GDP
- Rest : Out of Pocket
- Global Burden of Disease Report (2018) by LANCET Rank = 145
- Research suggests that $1 spent on nutritional interventions in India could generate $34 in public economic returns.
State of Health Services in India
- (Economic Survey) Prominence of Private Sector : Out of 4% expenditure on healthcare in India, Public Sector accounts for just 1.15%
- (Economic Survey) High Out of Pocket Expenditure (OoPE) : OoPE is as high as 62% (2014-15)
- Number of hospital beds per 1000 people – WHO average = 3.5 || India = 0.7.
- Planning commission => health problem pushes 39 million people every year under poverty line.
- Doctors unwilling to serve in Rural Areas .
- Dominance of Medical Council of India hindered development of nurses and other health cadres
Political & Constitutional Angle
- Health is under State list
- Debate going on – Should it be moved to Concurrent List given that even after 70 years of independence, state of health in India is still poor
- Centre can only make model laws to which states can voluntarily subscribe
- Article 47 of Indian Constitution (Directive Principle of State Policy) : State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties
- Article 21 – Right to Life
Health and SDG
- SDG 3 : Ensure Healthy Lives & Promote well being for all at all ages
1 . National Health Mission (NHM)
- It is Core Scheme (60:40 Division)
- It has two Components
|National Rural Health Mission (NRHM)||In areas having population below 50,000|
|National Urban Health Mission (NUHM)||In areas having population above 50,000|
2. Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP)
- Inexpensive, quality unbranded generic medicines will be made available through Jan Aushadi Stores
3. Mohalla Clinics
- Started by Delhi Government
- Primary Healthcare service near the house and has potential to solve ills like Out of Pocket Expenditure .
4. Rogi Kalyan Samiti
- Registered Society consisting of citizens of the area. Members act as trustees to manage the affairs of hospital.
- Act as check and increases accountability of doctors.
5. Mother and Child Health Schemes
|Under Health Ministry||1. Pradhan Mantri Surakshit Matritva Yojana |
2. Janani Suraksha Yojana
|Under Ministry of Women||1. Pradhan Mantri Matru Vandana Yojana |
2. Integrated Child Development Program
6. Immunization Programs
- Universal Immunization Program (UIP) against 12 diseases
- Mission Indradhanush
More about UIP and Mission Indradhanush explained below.
7. Menstruation Health
- Menstrual Hygiene for Adolescent Girls Scheme: To address the need of menstrual hygiene among adolescent girls residing in rural areas.
- Project Stree Swabhiman (by Ministry of Electronics and Information Technology)
- Menstrual Hygiene Scheme ( by Health Ministry as part of Rashtriya Kishor Swasthya Karyakram. )
- Rashtriya Madhyamik Shiksha Abhiyan (by Ministry of Human Resource Development)
8. Drug Price Control Order
- Drug Price Control Order (DPCO) is issued under the provisions of Essential Commodities Act .
- Schedule 1 of DPCO contains List of Essential Medicine (376) . Their price can’t be more than the fixed ceiling price .
- Mechanism to fix price
- Average of price of all brands having 1% market share
- Annual revision according to Wholesale Price Index
1 . Universal Immunization Program (UIP)
- Universal Immunization Program started by India in 1985
- Under Indian Immunisation Program, Vaccine is given for 12 life threatening diseases
|Original (7)||1. Diphtheria |
2. Whooping Cough
3. Tetanus (DPT)
7. Hepatitis B
|2016||4 more added |
8. Rotavirus (for Diarrhoea)
9. Inactivated Polio Vaccine Bivalent
10. Japanese Encephalitis for Adults
11. Measles and Rubella
|2017||1 more added |
Side Note : Pentavalent
Protects against 5 infections — diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae Type B (Hib) in one shot.
2. Mission Indradhanush
|Time Frame||– Christmas 2014 to 2020 |
|Target||Full and Free Vaccination to all Children and Pregnant Women|
|7 Diseases||1. Diphtheria |
2. Whooping Cough (Pertussis)
3. Hepatitis B
7. Measles – Rubella
In selected states , following diseases will also be covered
– Japanese Encephalitis
– Influenza Type B
Side Topic : Why People resist Vaccination ?
- Herd Immunity : When a critical number of children are vaccinated, it protects the “herd”, so that even non-vaccinated children are safe. Some parents begin to think that vaccinations are not needed.
- Misleading Comments : misleading comments on social media
derail vaccine programme. Statements like the vaccine is
introduced to induce impotence in children belonging to certain
- Muslim Community is very much vulnerable to this.
- 2018 Punjab : Similar rumours regarding Measles – Rubella
Public Health Policy , 2017
Previous Policy was given in 2002. There was need for new policy because
- 15 years have passed => new challenges have come up in health sector.
- At that time, Polio was major Problem. Now , WHO has declared India to be Polio Free
- That policy was keeping in view of Millennium Development Goals (MDG) . Now, we are in era of Sustainable Development Goals (SDG) .
- At that time , Communicable Diseases were major problem. Now Non Communicable Diseases have come into scene.
Main provisions of Public Health Policy, 2017
|Finance||– Present Government spending = 1.15 % of GDP |
– New Target under Public Health Policy = increase it to 2.5% of GDP by 2025 .
|Targets||Policy intends to|
1. Increase life expectancy at birth from 67.5 to 70 by 2025 .
2. Reduce premature mortality from Non Communicable Diseases (NCDs) by 25 per cent by 2025.
3. Achieve the global 2020 HIV target (also termed 90:90:90)
|Preventive and curative Care||This policy will rely on Preventive as well as Curative Health Care (2002 Policy = just Curative ) |
|Focus on Primary Care||Policy advocates allocating two-thirds (or more) of resources to primary care. |
|AYUSH||AYUSH to be promoted |
|Make in India Promote||Promote drugs and devices manufactured in the country.|
|Promote Male Sterilisation||Pushing up male sterilisation (Vasectomy) atleast by 30%.|
Criticism of the policy
- Abandoned idea to make health a right proposed under Draft Health Policy. NHP speaks of “assurance-based approach”.
- Raising Government Expenditure to 2.5% of GDP till 2025 is too far fetched given problem India facing is serious. Along with that no yearwise plan of yearly incrementation is given . There is lesser hope that even this will be attained given the past experience that health policy of 2002 had promised health expenditure of 2% of its GDP on health by 2010
- Governance issues are ignored : Silent on whether Health should be moved to Concurrent list
- Professional issues are ignored eg MCI issue , Private practice by Government doctors.
Issue : Out of pocket expenditure
- This topic has been frequently discussed in previous Economic Surveys. Hence, it is important topic.
- 5.5 Crore Indians fell into serious poverty-trap per year due to high health expenditure
- India’s out-of-pocket expenditure for health is one of the highest in the world, at 62 percent.(Global Average = 18%)
- Current expenditure on health is 4% of GDP out of which government spending is 1.15% and rest is private spending.
Why Out of Pocket Expenditure is high ?
- Low Public Health Expenditure by Government : Government spends just 1.15% of GDP on health
- No Insurance Cover (80% of population not covered under any insurance)
- Underfunded Drug Provisions : India allocates 0.1 % of GDP on publicly funded drugs
- Provider Induced Demand
- Changing Nature of Diseases to non-communicable diseases which isn’t covered by any public health system
Impact of high Out of Pocket Expenditure
- Large number of people are pushed into poverty because of this
- Increasing Inequalities in the society (according to Economic Survey of 2018)
- Causing feeling of relative deprivation in poor sections of society which can cause social unrest.
- Sizable amount of population doesn’t go for any treatment because of financial constraints
- Creates vicious cycle of poverty (Poverty Trap)
Steps Already Taken
- National Health Policy : Increase Health expenditure to 2.5% of GDP
- Ayushman Bharat
- Jan-Aushadi Stores
- National Free Diagnostic Initiative : to provide essential diagnostic services
- National Free Drug Initiative : expanding the availability of free drug in all public health facilities
- All the registered Medical practitioners directed by MCI to prescribe generic drugs & write name of salt instead of brand name
Way forward / How to control
- Pass Clinical Establishment Registration Act : To stop Provider Induced demands by doctors
- Increase health expenditures from their current level to at least 3 percent of the GDP
- Improve working of Jan Aushadhi stores
- Ensure a standard pricing system to bring parity on service cost