Download HEALTH FINANCING FOR PRIMARY HEALTHCARE IN RURAL …

Operationalising Right to Healthcare
in India
Paper presented at the
10th Canadian Conference on International Health
Ottawa 28th October 2003
Ravi Duggal
Centre for Enquiry into Health and Allied Themes
www.cehat.org
Healthcare in India
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Entitlements by policy and not rights
Focus on preventive and promotive care
Grossly under-provided facilities
Poor investments hitherto
Declining public expenditures and new
investments
SAPping the healthcare system
Rural-Urban Disparities – India
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RURAL (per 1000
population)
Hospital Beds = 0.2
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Doctors = 0.6
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Public Expenditures =
Rs.80,000
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Out of pocket =
Rs.750,000
____________________
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IMR = 74/1000 LB
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U5MR = 133/1000 LB
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Births Attended = 33.5%
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Full Immunz.=37%
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Median ANCs=2.5
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URBAN (per 1000
population)
Hospital Beds = 3.0
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Doctors = 3.4
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Public Expenditures =
Rs.560,000
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Out of Pocket =
Rs.1,150,000
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IMR = 44/1000 LB
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U5MR = 87/1000 LB
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Births Attended = 73.3%
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Full Immunz.= 61%
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Median ANCs=4.2
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Expenditure Patterns
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Public expenditures –declining trends
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LPG and growth of private capital and
stagnation of public investment
Reduced public spending
Out of pocket – increasing burden,
especially the poor and in rural areas
Character of Health Expenditures
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Public Domain
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Rural/Urban divide
Preventive/Curative dichotomy
Plan/Non-plan expenditures
Centre, State and Local governments
Private Domain
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Curative only- pharma industry driving force
Irrational practices, malpractice, unregulated, lack of
professional ethics
Supply induced demand
Facts & Figures - Health Spending
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Public Domain
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Centre: Rs.35 bi (0.13% GDP)
State: Rs.186 bi (0.72% GDP)
Local: Rs.25 bi estimated (0.10% GDP)
Social Insurance: Rs. 12 bi (0.05% GDP)
Private Domain
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Out-of-pocket: Rs.1200 bi (4.62% GDP)
Insurance (public sector) Rs.8 bi (0.03% GDP)
Pharma Industry Rs. 250 bi (0.96% GDP)
Healthcare Financing – Rs. billion
1993 1994- 1995- 1996- 1997- 2000- 2002-94 95
96
97
98
01
03BE
Public
Centre
State
7
68
11
72
12
89
13
99
14
113
23
156
35
186
Total
%Govt
%GDP
Private
%GDP
75
2.91
0.87
195
2.27
83
2.13
0.81
279
2.75
101
2.98
0.86
329
2.77
112
2.94
0.83
373
2.73
127
2.70
0.83
459
3.00
179
2.91
0.81
982
4.46
221
3.17
0.85
1200
4.62
Source: Public Expenditures - Finance Accounts upto 2001 and Budget for 2003; Private – CSO estimates
on Consumption Expenditure 1985 series; BE = Budget Estimate
Basic Care Framework
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What constitutes basic health services
Family physician services, supported by
paramedics and community health workers
 First level referral hospital with basic specialties
and ambulance services
 Epidemiological services, including information
management and health education
 Maternity services for safe pregnancy, abortion,
delivery and postnatal care
 Immunisation services against vaccine
preventable diseases
 Pharmaceutical and contraceptive services
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Operational Mechanism
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Restructuring and Reforms
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Organising a system
Creating an autonomous health authority
Referral system
Standards and regulation
Structured financing
Operational Mechanism...
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Priorities for making it work
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An Act of Parliament - Health Authority
Tackling the medical profession
Licensing, registration, minimum standards
Integration of systems
Continuing medical education
Pricing mechanisms
Raising substantial additional resources
Consensus building in civil society
Financing the System
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Resource Requirements
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Present public spending on health care is less than
1% of GDP and out-of-pocket is 4%
Reorganised system will need totally 3% of GDP
Costs will be shared by governments at all levels,
employers, employees, earmarked taxes and
cesses, insurance funds etc..
Innovations in Financing
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Using existing resources efficiently and
effectively
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Decentralised governance (Panchayati Raj)
Block funding or global budgeting
Leads to equity in access to resources
PHC level resources tripled
CHC and district level resources doubled
Innovations in Financing…
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Generating additional resources
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Increased allocations within the existing budget
Payroll taxes for health like profession tax
Health cess on health degrading products, polluting
industry and luxury products
Compulsory public service by those graduating
from public medical schools
Social security levies on land revenues
Consensus Building
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Policy level advocacy for UHC
Research to develop framework
Lobbying with medical profession
Filing of PIL for RTHH
Lobbying MPs to demand justiciability of
directive principles
National and regional consultations on RTHH
involving civil society
Consensus Building…
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Campaigns on RTHH with networks of people’s
organisation
Bringing RTHH on manifestoes of political
parties
Pressurising international bodies like Committee
of ESCR, WHO,UNCHR.. And national bodies
like NHRC, NCW.. To monitor state obligations
and demand accountability
Shadow reports on RTHH
Summary and Conclusions
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Rural – Urban disparities across the board
Reduced investments and expenditures on health care in
the nineties has impacted access and health outcomes
Allocative inefficiencies coupled with SAP only makes
the crises of public healthcare worse
Overall health outcomes not very good because of the
worsening access to healthcare –user charges and
privatisation
Lack of accountability
The need for a right to healthcare perspective