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