Panna Dhai Maa Subharti Nursing

College
TOPIC: HEALTH CARE DELIVERY SYSTEM
AMRITANSHU CHANCHAL M.SC(2 ND YEAR)
 Health Care Delivery System

 Health care is the prevention, treatment, and management of illness and the
preservation of mental and physical well being through the services offered by
the medical, nursing, and allied health professions.
 According to the World Health Organisation, health care embraces all the
goods and services designed to promote health, including “preventive,
curative and palliative interventions, whether directed to individuals or to
populations”.
 Health is defined as a state of complete physical, mental and social well being
and just not the non existence of disease or ailment. Health is a primary
human right and has been accorded due importance by the Constitution
through Article 21.Though Article 21 stresses upon state governments to
safeguard the health and nutritional well being of the people, the central
government also plays an active role in the sector. Recognizing the critical role
played by the Health Industry, the industry has been conferred with the
infrastructure status under section 10(23G) of the Income Act.
 The Indian Health sector consists of

• Medical care providers like physicians, specialist clinics, nursing homes,

hospitals.
• Diagnostic service centers and pathology laboratories.
• Medical equipment manufacturers.
• Contract research organizations (CRO's), pharmaceutical manufacturers
 Health Care Sector in India : A Historical Perspective

 Before Independence: Conventionally health care in India has been based on

voluntary work. Since ancient times traditional practitioners of health care
have contributed to the medicinal needs of society. Acute knowledge in the
medicinal properties of plants and herbs were passed on from one generation
to another to be used for treatment. The colonial rule and the dominance of the
British changed the scenario. Hospitals managed by Christian missionaries
took centre stage. Even the intellectual elite in India with their pro west bias
favored Western practices.
 After Independence

 Prior to independence the healthcare in India was in shambles with large

number of deaths and spread of infectious diseases. After independence the
Government of India laid stress on Primary Health Care and India has put in
sustained efforts to better the health care system across the country. The
government initiative was not enough to meet the demands from a growing
population be it in primary, secondary or tertiary health care. Alternate sources
of finance were critical for the sustainability of the health sector.
 Entry of Private Sector

 About 20 years back, the private sectors venture in the health care sector
consisted of only solo practitioners, small hospitals and nursing homes. The
quality of service provided was excellent especially in the hospitals run by
charitable trusts and religious foundations. In 1980's realizing that the
government on its own would not be able to provide health care, the
government allowed the entry of private sector to reduce the gap between
supply and demand for healthcare. The private hospitals are managed by
corporate, non-profit or charitable organizations. The establishment of
private sector has resulted in the emergence of opportunities in terms of
medical equipment, information technology in health services, BPO,
Telemedicine and medical tourism.
 Health care system in India

Traditional Healthcare Systems in India

 In India, in addition to existence of modern medicine, indigenous or
traditional medical practitioners continue to practice throughout the country.
Popular indigenous healthcare traditions include Ayurveda, Siddha, Unani,
Homeopathy, Naturopathy, and Yoga. The Ayurveda (meaning science of life)
system deals with causes, symptoms, diagnoses, and treatment based on all
aspects of well-being (mental, physical, and spiritual). These professionals,
traditionally, have been inheriting the skills from their ancestors. However,
with the advent of education, a variety of institutions offer training in
indigenous medical practice.
 The Siddha system defines disease as the condition in which the normal
equilibrium of the five elements in human beings is lost resulting in different
forms of discomfort. The diagnostic methods in Siddha medical system are
based more on the clinical acumen of the physician after observation of the
patient, pulse and diagnosis and clinical history.
 Yoga is a science as well an art of healthy living physically, mentally, morally
and spiritually. Yoga is believed to be founded by saints and sages of India
several thousand years ago. Yoga has its origin in the Vedas, and its
philosophy is an art and science of living in tune with the universe. Yogis gave
rational interpretation of their experiences about Yoga and brought a
practically sound and scientifically prepared method within every one’s reach.
 Naturopathy has several references in the Vedas and other ancient texts, which
indicate that these methods were widely practised in ancient India.
Naturopathy believes that all the diseases arise due to accumulation of morbid
matter in the body and if scope is given for its removal, it provides cure or
relief. It also believes that the human body possesses inherent self-
constructingand self-healing powers. Naturopathy differs slightly with other
systems of medicine, as it does not believe in the specific cause of disease and
its specific treatment but takes into account the totality of factors responsible
for diseases such as one’s un-natural habits in living, thinking, working,
sleeping, or relaxation, and the environmental factors that disturbs the normal
functioning of the body.
 Unani system of medicine believes that the body is made up of four basic
elements viz., earth, air, water and fire, which have different temperaments i.e.
cold, hot, wet and dry. After mixing and interaction of four elements a new
compound having new temperament comes into existence i.e. hotwet, hot-dry,
cold-wet and cold-dry. The body has simple and compound organs, which got
their nourishment through four humours, viz. blood, phlegm, yellow bile,
black bile. Unani system of medicine believes in promotion of health,
prevention of diseases and cure.
Modern (Allopathic) Healthcare Systems in India

 The modern (allopathic) health care system in India consists of a public sector,
a private sector, and an informal network of care providers. The size, scale,
and spread of the country hampered complete adherence to the number of
well-intended guidelines and regulations. Although there are norms and
guidelines, compliance is minimal. In reality, the sector operates in a largely
unregulated environment, with minimal controls on what services can be
provided, by whom, in what manner, and at what cost. Thus, wide disparities
occur in access, cost, levels, and quality of health services provided across the
country.
 India’s health system can be categorized into three distinct phases:

 In the initial phase of 1947-1983, health policy was assumed to be based on

two broad principles:
 that none should be denied healthcare for want of ability to pay,
 that it was the responsibility of the state to provide healthcare to the
people.This phase saw moderate achievements.
 In the second phase of 1983-2000, a National Health Policy was announced
for the first time in 1983, which articulated the need to encourage private
initiative in healthcare service delivery and encouraged the private sector to
invest in healthcare infrastructure through subsidies. The policy also enhanced
the access to publicly funded primary healthcare, facilitating expansion of
health facilities in rural areas through National Health Programmes (NHPs).
 The third phase, post-2000, is witnessing a further shift and broadening of
focus; the current phase addresses key issues such as public-private
partnership, liberalization of insurance sector, and the government as a
financier.
 Role of Public Sector in Health Care

 The public healthcare system consists of facilities run by the central and state
government. These public facilities provide free or subsidized rates to lower
income families in rural and urban areas.The Constitution of India divides
health-related responsibilities between the central and the state governments.
While the national government maintains responsibility for medical research
and technical education, state governments shoulder the responsibility for
infrastructure, employment, and service delivery. The concurrent list (in the
9th schedule to the Constitution of India) includes issues that concern more
than one state, e.g., preventing extension of infectious or contagious diseases
among states. While the states have significant autonomy in managing their
health systems, the national government exercises significant fiscal control
over the states’ health systems.
Organizational Flowchart
 Ministry of health and family welfare

 The Ministry of Health & Family Welfare is instrumental and responsible

for implementation of various programmes on a national scale in the areas of
Health & Family Welfare, prevention and control of major communicable
diseases and promotion of traditional and indigenous systems of medicines.
Apart from these, the Ministry also assists States in preventing and controlling
the spread of seasonal disease outbreaks and epidemics through technical
assistance. Ministry of Health & Family Welfare incurs expenditure either
directly under Central Schemes or by way of grants–in–aids to the
autonomous/ statutory bodies etc. and NGOs. In addition to the 100%
centrally sponsored family welfare programme, the Ministry is implementing
several World Bank assisted programmes for control of AIDS, Malaria,
Leprosy, Tuberculosis and Blindness in designated areas. Besides, State
Health Systems Development Projects with World Bank assistance are under
implementation in various states.
 The projects are implemented by the respective State Governments and the
Department of Health & Family Welfare only facilitates the States in availing
of external assistance. All these schemes aim at fulfilling the national
commitment to improve access to Primary Health Care facilities keeping in
view the needs of rural areas where the incidence of disease is high.
 The Ministry of Health & Family Welfare comprises the following
departments, each of which is headed by a Secretary to the Government of
India:- 1)Department of Health & Family Welfare 2)Department of AYUSH
3)Department of Health Research 4)Department of AIDS Control
 The health care infrastructure in rural areas has been developed as a
three tier system :
 Subcenters - In rural areas, health sub-centres form the institutional basis of
primary health care. It typically performs basic medical services,
immunizations, and referrals. Subcenters are usually temporary structures that
employ 1–2 care workers in most locations. Concerns include inadequate
and/or uneven geographic coverage and inadequate funding. Each sub-centre
is supposed to provide essential services for up to 5,000 individuals. Jointly
with other institutions, they also provide family planning and other public
health programmes (e.g., hygiene and water purity programmes) that are
supposed to be carried out by paramedical personnel such as auxiliary nurse
midwives.
 The sub-centres are complemented by community health workers under
supervision of the subcentre. These community members provide essential
health care on a part-time basis. A three-month training course is supposed to
enable them to perform first aid according to traditional and allopathic
principles.
 Primary health centers (PHCs) typically perform preventive and curative
medical services. PHCs are usually small (about 5 beds) with 1–2 qualified
doctors, and 14 paramedics and support staff. Each PHC is typically a referral
unit for a subcenter cluster of about six. Concerns include inadequate and
uneven geographic coverage and insufficient number of qualified doctors and
staff. The primary health care centres (PHC) are in charge of six sub-centres
each. Besides outpatient treatment, most PHCs offer inpatient treatment with
four to six beds. According to the plan, each PHC serves 30,000 people and
employs one physician supported by 14 staff members.
 The secondary sector of the Indian health care system consists of rural
hospitals and community health centres (CHC). Serving four PHCs, the
CHC’s specialised medical services are intended for 120,000 people. For
several years now, there have been plans to upgrade 2,000 CHCs to the status
of regional hospitals. Community health centres are supposed to have at least
30 beds, an operating theatre, a laboratory, xray facilities, as well as a team of
four medical specialists and a support staff of 21.
 Role of Private Sector in Healthcare

 India is encouraging investment in healthcare sector; over the years, the

private sector in India has gained a significant presence in all the sub-
segments of medical education and training, medical technology and
diagnostics, pharmaceutical manufacture and sale, hospital construction and
ancillary services, as also the provisioning of medical care. Over 75% of the
human resources and advanced medical technology, 68% of hospitals and 37%
of total beds in the country are in the private sector. The composition of
private sector in India is diverse with large number of sole practitioners or
small nursing homes having bed capacities of less than 20.
 There are also several corporate entities, including pharmaceutical firms, and
non-resident Indians (NRIs), who have invested in the Indian healthcare sector
and are providing world-class care at a fraction of the cost compared to many
developed countries. In addition, there are also traditional healthcare
providers, such as Ayurveda and Yoga, who have set up facilities. It is reported
that there are 1369 hospitals with a bed capacity of over 53000 in India
catering to the needs of traditional Indian healthcare; about 726,000 registered
practitioners are working under the traditional healthcare system. Indian hotels
are also entering the wellness services market offering Spas and Ayurvedic
massages, tying up with professional organizations in a range of wellness
fields.
 The public sector must reorient its dual role of financing and provision of
services because of its increasing inability on both fronts. Under partnerships,
public and private sectors can play innovative roles in financing and providing
health care services. While reviewing the health sector in India, the World
Bank and the National Commission on Macroeconomics in Health strongly
advocated harnessing the private sector’s energy and countering its failures by
making both public and private sectors more accountable.
 Health Infrastructure

 Health Infrastructure is an important indicator to understand the healthcare

delivery provisions and mechanisms in a country. It also signifies the
investments and priority accorded to creating the infrastructure in public and
private sectors.The health infrastructure in India is spread over the different
systems of medicine such as allopathic, ayurveda, siddha, Tibetan medicine,
unani and homoeopathy, and can be categorized as follows: a) Pysical
infrastructure b) Human resources.
 Physical Infrastructure

 The physical infrastructure consists of health facilities in the public sector

and those provided by the private sector. Public health services consist of a
network of sub-centres, primary health centres (PHC), community health
centres (CHC) and district hospitals. The infrastructure in the private sector
provides at least 80 per cent of health services in the country and can be
classified as follows: • Private dispensaries • Private hospitals • Charity
hospitals, including medical centres managed by NGOs• Corporate hospitals
Density of health care worker
 Expenditure on Health Health expenditure covers the provision of preventive
and curative health services, public health affairs and services, health applied
research, and medical supply and delivery systems, but it does not include
provision of water and sanitation.
Growth and Prospects of Health Sector in India

 Healthcare has emerged as one of the most progressive and largest service
sectors in India. The health care sector in India has been growing at an
enormous pace. During 2002, India's health care industry contributed 5
percent to the GDP and employed approximately 4 million people. By 2012
this industry is projected to contribute 8.5 percent of the GDP. At present the
sector is estimated to be around US$ 40 billion and will grow to US$ 78.6
billion by 2012. The Indian healthcare market is estimated to be US$ 30
billion and includes pharmaceuticals, healthcare, medical and diagnostic
equipment and surgical equipment and supplies. The Indian healthcare sector
is expected to become a US$ 280 billion industry by 2020 with spending on
health estimated to grow 14 per cent annually.
 Private health care will form a large chunk of this spending, rising from
US$14.8 billion to US$33.6 billion in 2012. Private spending accounts for
almost 80 per cent of total healthcare expenditure. The public sector however
is likely to contribute only around 15-20 per cent of the required US$ 86
billion investment. The corporate India is therefore, leveraging on this
business potential and various health care brands have started aggressive
expansion in the country. Some of the companies that plan to increase their
footprints include Anil Ambani’s Reliance Health, the Hindujas, Sahara
Group, Emami, Apollo Tyres and the Panacea Group.
 The rural healthcare sector is also on an upsurge. The Rural Health
Survey Report 2009, released by the Ministry of Health, stated that during
the last five years rural health sector has been added with around 15,000
health sub-centres and 28,000 nurses and midwives. The report further
stated that the number of primary health centres have increased by 84 per
cent, taking the number to 20,107. The size of the Indian medical
technology industry may touch US$ 14 billion by 2020 from US$ 2.7
billion in 2008 on account of strong economic growth, higher public
spending and private investments in healthcare, increased penetration of
health insurance and emergence of new models of healthcare delivery.
 Recent Health Improvements

 The improvement in the quality of health care over the years is reflected in
respect of some basic demographic indicators. The Crude Birth Rate (CBR)
has declined from 40.8 in 1951 to 29.5 in 1991 and further to 22.8 in 2008.
Similarly there was a sharp decline in Crude Death Rate (CDR) which has
decreased from 25.1 in 1951 to 9.8 in 1991 and further to 7.4 in 2008. Also,
the Total Fertility Rate (average number of children likely to be born to a
woman between 15-44 years of age) has decreased from 6.0 in 1951 to 2.6 in
the year 2008 as per the estimates from the Sample Registration System (SRS)
of Registrar General India (RGI), Ministry of Home Affairs. The
 Maternal Mortality Rate has also declined from 437 per one lakh live births in
1992 – 93 to 254 in 2004-06 SRS, according to the Report brought out by
RGI. Infant Mortality Rate, which was 110 in 1981, has declined to 53 per
1000 live births in 2008. Child Mortality Rate has also decreased from 57.3 in
1972 to 15.2 in 2008.
 Institutional births, a main focus of the National Rural Health Mission, have
increased from 41% in 2004 to 47% in 2008. Nevertheless, meeting the
Millennium Development Goal (MDG) for infant mortality of 27 per 1000
live births by 2015 represents a formidable challenge.
 Prevalence rates of HIV, TB and malaria are in sustained decline. The national
AIDS program is well on track in achieving its coverage targets. The
government's TB program exhibits adequate implementation of DOTS
activities across the country, with good outcomes in case detection and cure
rates at the national level.
 Health Care Situation : Areas of Concern

 79.1% of children from 6 months to 5 years of age are anaemic.

 56.1% ever married women aged 15-49 are anemic.
 Infant Mortality Rate is 58/1000 live births for the country with a low of 12
for Kerala and a high of 79 for Madhya Pradesh.
 Maternal Mortality Rate is 301 for the country with a low of 110 for Kerala
and a high of 517 for UP and Uttaranchal in the 2001-03 period.
 Two thirds of the population lack access to essential drugs.
 80% health care expenditure born by patients and their families as out-of
-pocket payment (fee for service and drugs)
• Health inequalities across states, between urban and rural areas, and across
the economic and gender divides have become worse
• Health, far from being accepted as a basic right of the people, is now being
shaped into a saleable commodity
• poor are being excluded from health services
• Increased indebtedness among poor (Expenditure on health care is second
major cause of Indebtedness among rural poor)
• Difference across the economic class spectrum and by gender in the
untreated illness has significantly increased cutbacks by poor on food and
other consumptions resulting increased illnesses and increasing
malnutrition
 Health Insurance

 The growing affluence of the Indian middle-class accompanied with lifestyle-

related diseases and inflationary healthcare costs are driving the demand for
health insurance in India today. Launch of new hospital chains with a stress on
holistic well-being is further accentuating this demand, especially in urban
areas. Meanwhile the government, in collaboration with non governmental
organisations and insurers, is launching various schemes to provide low cost
health insurance facility to all citizens. All factors combined contributed to the
nearly 40% compound annual growth rate (CAGR) in premiums of health
insurance since the sector’s liberalisation a decade ago.
 The Indian health insurance market has emerged as a new and lucrative
growth avenue for both the existing players as well as the new entrants. The
health insurance market represents one the fastest growing and second
largest non-life insurance segment in the country. The Indian health
insurance market has posted record growth in the last two fiscals (2008-09
and 2009-10). Moreover, as per the report, the health insurance premium is
expected to grow at a CAGR of over 25 per cent for the period spanning
from 2009-10 to 2013-14. However, certain intrinsic factors inhibit this
segment from reaching its fullest potential. On the one hand, low awareness
and lack of understanding of product features, in addition to perceived
apprehension in claims procedures and settlement, intimidates consumers
from buying a health cover.
 Key Challenges

 Maternal and child health: Only about half of pregnant women receive
adequate antenatal coverage - at least three visits during one pregnancy. This
percentage remains low and stagnant. While the percentage of children
between 12-23 months of age that are fully immunized rose from 46% in 2004
to 54% in 2008, these levels remain unacceptably low.
 Childhood nutrition: Despite the largest child-nutrition program in the world,
rates of childhood malnutrition have remained unchanged for nearly two
decades: 48% of children under the age of five are stunted (low height for
age), 43% are underweight (low weight for age), and 20% are wasted (low
weight for height).
 New diseases on the rise: At the same time, new health challenges are
emerging. The rise in chronic adult diseases and injuries is stretching the
system’s capacity to respond. Non-communicable diseases and injuries already
account for about 60% of India’s disease burden, led by cardiovascular
disease, mental health, injuries, cancer, and diabetes.
 Unfinished agenda of communicable diseases: Although the prevalence of
HIV has recently been lowered to an estimated 0.41% of the adult population,
or approximately 2.5 million individuals, this still poses a very significant
burden and requires continued efforts to avoid a devastating, more generalized
epidemic. Tuberculosis, malaria, polio, and dengue fever still remain serious
threats in a number of states
 Financial burden: At over 70% of all health spending, out-of-pocket
expenditures are by far the main financing mechanism for health care in India.
This poses considerable financial burden on households. Based on the
National Sample Survey (60th round), in 2004, 63 million individuals or 12
million households fell into poverty due to health expenditures (6.2% of all
households). The majority of these households (79%) became impoverished
due to spending on outpatient care, including drugs, and the remainder (21%)
fell into poverty due to hospital care.
 Shortage of trained medical personnel : India faces a huge shortage of
trained medical personnel, including doctors, nurses and especially
paramedics, who may be more willing than doctors to live in rural areas where
access to care is limited. There is an immediate need for medical education
and training, which could provide additional opportunities for private sector
providers or public-privatepartnerships (PPP).
 Conclusion

 India’s health scenario currently presents a contrasting picture. While health

tourism and private healthcare are being promoted, a large section of Indian
population still reels under the risk of curable diseases that do not receive
adequate attention of policymakers. India’s National Rural Health Mission is
undeniably an intervention that has put public heath care upfront. Although the
government has been making efforts to increase healthcare spending via
initiatives like the National Rural Health Mission, much still remains to be
done. The priority will be to develop effective and sustainable health systems
that can meet the dual demands posed by the growth in non communicable
diseases and peoples’ needs for better quality and higher levels of health care.
 Reference

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International Institute for Population Sciences (IIPS) and ORC Macro
(2007). National family health survey (NFHS-3), 2005–06, India: Volume I.
Mumbai: IIPS. National Commission on Macroeconomics and Health
(2005).
Financing and delivery of health care services in India. New Delhi:
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Thank you