The Unmet Objective of Health Financing in India. Affordable Health Care for All

CONTENTS:

LIST OF TABLES:

LIST OF FIGURES:

ACKNOWLEDGEMENTS:

LIST OF ABBREVIATION:

GLOSSARY:

ABSTRACT

INTRODUCTION

CHAPTER 1 BACKGROUND INFORMATION
1.1. GEOGRAPHY
1.2. GOVERNANCE AND ADMINISTRATION:
1.3. POPULATION:
1.4. NATIONAL CURRENCY:

CHAPTER 2 PROBLEM STATEMENT, JUSTIFICATION, AND OBJECTIVES
2.1. PROBLEM STATEMENT:
2.2. JUSTIFICATION:
2.3. OBJECTIVES:
2.4. METHODOLOGY:
2.5. SEARCH STRATEGY:
2.6. EXCLUSION CRITERIA:
2.7. FRAMEWORK:
2.8. KEYWORDS:
2.9. LIMITATIONS:

CHAPTER 3 STUDY RESULTS FINDINGS
3.1. GROSS DOMESTIC PRODUCT (GDP) GROWTH RATES:
3.2. ACTORS INVOLVED IN STEWARDSHIP FUNCTIONS:
3.3. HEALTHCARE SYSTEM, SERVICE DELIVERY AND INFRASTRUCTURE:
3.4. HUMAN RESOURCES FOR HEALTH:
3.5. LEGAL AND REGULATORY FRAMEWORK FOR HEALTH FINANCING:
3.6. KEY ACTORS IN HEALTH FINANCING:
3.7. HEALTH EXPENDITURE IN INDIA:
3.8. RESOURCE COLLECTION:
3.9. POOLING:
3.10. PURCHASING:

CHAPTER 4 DISCUSSION:

CHAPTER 5 CONCLUSION AND RECOMMENDATION:

Reference:

LIST OF TABLES:

Table 1 Human Development Index, Child Mortality Indicators And Incidence Of Tuberculosis In India And Neighboring Countries; 2016

Table 2 Institutional Delivery, Antenatal Care And Immunization Across The Wealth Quintile In India

Table 3 Percentage Distribution Of Under-Five Mortality, Infant Mortality, Neonatal Mortality, Across The Wealth Quintile

Table 4 Percent Of Household Reporting As A Source Of Finance For Meeting The Medical

Expenditure From A Rural And Urban Area From Different Wealth Quintile 2015-16

Table 5 Health Financing Function With Their Performance Indicator

Table 6 Operationalization Of Each Indicator

Table 7 Health Financing Function With Key Word Used

Table 8 Financing Indicators And Public Health Services

Table 9 Source Of Health Care Provider Across Wealth Index And Rural Urban Area.

Table 10 Key Health Financing Indicators For India 2015-16

Table 11 Source Of Tax As A Percent Of Gdp From Financial Year; 2013-14 To 2016

Table 12 Revenue From Health Insurance Schemes

Table 13 Health Insurance Scheme By Residence And Wealth Quintile 2015-16

Table 14 Expenditure Of Health Insurance Agencies

Table 15 Public Health Insurance Scheme Institutional Design

Table 16 Health Insurance Scheme With Benefit Package And Payment Mechanism

Table 17 Health Insurance Scheme-Wise Benefit Package

Table 18 Current Health Expenditure By Health Care Goods And Services

Table 19 Package Rate Difference By Health Insurance Scheme

LIST OF FIGURES:

Figure 1 Percent Distribution Of The Urban And Rural Population By Wealth Quintile

Figure 2 Institutional And Organizational Assessment For Improvement And Strengthening Health Financing(Oasis) Analytical Framework

Figure 3 Iercentage Of Registered Ayush Doctors In India

Figure 4 Flow Of Funds

Figure 5 Trend Of Union, State Government Share As % In Total Public Expenditure On Health

Figure 6 Trend In Unspent Balance

Figure 7 Under Utilization Of Funds By State Government

Figure 8 Trend In Government Health Expenditure

Figure 9 Government Health Expenditure And Out-Of-Pocket Expenditure

ACKNOWLEDGEMENTS:

I want to thank God for giving me the strength to complete my thesis writing. I express my deepest gratitude to my thesis advisor and my thesis back for giving their support during writing.

I also want to thank all the tutor and administrative staff of the Royal Tropical Institute for their generous support throughout the course.

Many thanks to Orange Knowledge Program for providing the opportunity to learn in the Royal Tropical Institute.

Last but not least, I thank my parents and my wife for giving me support throughout the course as well as thesis writing.

LIST OF ABBREVIATION:

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GLOSSARY:

Capital Expenditure: Expenditure on building capital assets, renovations and expansions of buildings, purchasing of vehicles, machines, equipment, medical/ AYUSH/ paramedical education, research and development, training (except on the job training), major repair work(50).

Current Health Expenditure: Final consumption expenditure of resident units on healthcare goods and services(50).

Household Health Expenditure: Sum of direct expenditures (out of pocket payments) and indirect expenditures (prepayments as health insurance contributions or premiums)(50).

Out-of-Pocket Expenditure: Out-of-pocket expenditure(OOP), medical costs that households bear at the time of availing healthcare service(50).

Total Health Expenditure (THE): Total health expenditure is the sum of current health expenditure and capital health expenditure in the same financial year(50).

Public Health Care Facilities (Public Facilities): It includes medical college hospitals, district hospitals, sub-district hospitals, and community health centers(50).

Government Health Expenditure: It includes expenditures from union and state government, rural and urban local bodies including quasi-governmental organizations and donors in case funds are channeled through government organizations(50).

Government Transfers: It includes funds allocated from government domestic revenues for health purposes. fund is allocated through internal transfers and grants(50).

Gross Domestic Product(GDP): The total money value of all final goods and services produced in an economy over a period of one year(28).

Total Health Expenditure (THE) as percent of GDP and Per Capita: THE constitutes current and capital expenditures incurred by government and private sources including external funds. Total health expenditure as percentage of GDP indicates health spending relative to the country’s economic development. THE per capita indicates health expenditure per person in the country(50).

Current Health Expenditures (CHE) as percent of THE: Current health expenditure constitutes only recurrent expenditures for healthcare purposes net all capital expenditures. Current health expenditure as percent of THE indicate the operational expenditures on healthcare that impact the health outcomes of the population in that particular(50).

Government Health Expenditure (GHE) as percent of THE: government health expenditure constitutes spending under all schemes funded and managed by union, state and local governments including quasi-governmental organizations and donors in case funds are channeled through government organizations(48).

Social Security Expenditure on health as per cent of THE: Social security expenditures include finances allocated by the government towards payment of premiums for union and state government financed health insurance schemes (RSBY and other state specific health insurance schemes), employees’ benefit schemes or any reimbursements made to government employees’ for healthcare purposes and social health insurance scheme expenditures. This indicates extent of pooled funds available for specific categories of population(49).

External/Donor Funding for health as percent of THE: This constitutes all funding available to the country by assistance from donors agencies(50).

Out of Pocket Expenditures (OOPE) as percent of THE: This indicates extent of financial protection available for households towards healthcare payments(50).

Private Health Insurance Expenditures as percent of THE: Private health insurance expenditures constitute spending through health insurance companies wherein households or employers pay a premium to be covered under a specific health plan. This indicates the extent to which there are voluntary prepayments plans to provide financial protection.

Government Health Expenditure as % of General Government Expenditure (GGE): This is a proportion of share of government expenditures towards healthcare in the general government expenditures and indicates government’s priority towards healthcare(50).

Household Health Expenditure as % of THE: Household health expenditures constitute both direct expenditures (OOPE) and indirect expenditures (prepayments as health insurance contributions or premiums)(50).

Union and State Government Health Expenditure as % of GHE: The union government health expenditures includes the funds allocated by different ministries and departments of union government towards healthcare of general population and its employees. Similarly the state government health expenditure includes the funds allocated by different departments under all the state governments towards healthcare of general population and its employees’(50).

Pharmaceutical Expenditures as % of CHE: This includes spending on prescription medicines during a health system contact and self-medication(often referred to as over-the- counter products) and the expenditure on pharmaceuticals as part of inpatient and outpatient care from prescribing physicians(50).

ABSTRACT

Introduction: In India, healthcare costs are increasing and India’s health financing system is exacerbating economic burden on household because of health expenditure and influence treatment-seeking behaviors. As a result, health inequity and unequal access, come up as the main concern for the Indian Health care system. This study aims to report the bottlenecks in health financing functions resulting in financial barrios in health care access.

Methodology: Literature review and desk study were done by reviewing, analyzing the data from national health account and National Family Health Survey conducted during 2012-13 to 2015-16 and analysis of studies done on health system and Health financing functions in India were included. The OASIS framework used to guide the study.

Result: Inability of the state government to utilize available funds and inadequate public spending on health result in out-of-pocket expenses, as the most significant source of revenue for health financing, and poses a barrier to access for healthcare, as inadequate availability and poor-quality of services given by public facilities push the patient to costly private health-care services.

Twenty eight percent of the Indian population have medical insurance indicating inadequate financial protection against unseen medical cot; Fragmentation of Health insurance schemes and corruption are factors for low coverage.

Also, benefit-packages varies among schemes in respect of number of available packages and the annual spending limit.

Discussion: Inadequate financial protection and high household expenditure on health including out of pocket expenditure, resulting in catastrophic spending and may push the household below the poverty line and have negative impact on health seeking behavior and utilization of available health care services.

Recommendations: To remove financial barrier, government must priorities health in public policy, public spending on health should increase, state government should utilization available funds efficiently and should consider one nation one health insurance.

Keywords: Sources of financing, intersectional approach, out-of-pocket payments, health care financing, India

Word Count: 12,160

INTRODUCTION

Globally, total spending on health is increasing faster than the gross domestic product (GDP). The trend in public spending on health is also increased over time, in terms of total health spending, but it is still inadequate in most of the LMICs(1). With economic growth and advancement in medical science life expectancy in India has increased; however, this advancement is accompanied by costly medicines, and the diagnostic procedure has increased the healthcare cost. Increased health care cost has limited the affordability of health care services to most of the Indians(2).

The government of India recognizes the need for quality health services which is affordable to all and attempting to increase government spending on health, the Indian government launched national schemes to ensure affordable health care services and financial protection to its citizens and aiming better health outcomes and(3). However, despite these measures, India is still among the top ten countries with high out of pocket payments(8).

Out of pocket payment expenditure(OOPE) is considered to be a most regressive form of financing and indicates an inefficient mechanism of prepayment, risk-pooling, and cross- subsidization and as a consequence, OOP results in catastrophic expenditure on health and may end in impoverishment.

In my clinical practice, I had experienced a scenario where patients had to stop receiving therapy due to financial hardship or lend cash in order to continue therapy.

I have seen families who do not even go to a health care provider due to their inability to pay user fees

This paper will look at the challenges of existing health financing systems to answer why the existing health financing mechanism in India is not able to provide needed health care without financial hardship.

CHAPTER 1 BACKGROUND INFORMATION

The Republic of India is not only a “Union of State” and a sovereign, secular, socialist, democratic republic, as described by its constitution (5) but is a home for different ethnic groups from the different races following different religion and cultural practices and speaks different languages.

PICTURE 1 POLITICA L MAP OF INDIA (6)

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1.1. GEOGRAPHY:

The land of the country consists of four regions, namely, the mountain zone, plains of the Ganga and the Indus river, the desert region, and the southern peninsula (7)

1.2. GOVERNANCE AND ADMINISTRATION:

Governance and administration of the country is done by a parliamentary form of government which is federal in structure and comprises union government, a council of ministers headed by prime minister, similarly state government a council of minister's head by chief minister, and local bodies denominated as municipalities in cities/towns and panchayats in villages. All the ministers in the government and local bodies are elected democratically as per the constitution of India (8).

India, geographically located in the south Asia region is the second most populated country in the world, has an annual population growth rate of 1.19% (9).

1.3. POPULATION:

An estimated current population of India is 1.3 billion, of which 750 million, are in the age group of 15-59 who are considered as an economically active population and 350 million are in age bracket of 0-14 whereas 125 million are aged more than 60 years(10), living in urban area (27%) comprises ( 640 districts, 5988 sub-districts, 7933 town) and rural (73%) area ( 640932 villages), of 29 states and 7 union territories (11).

1.4. NATIONAL CURRENCY:

The national currency of India is Indian national rupee (INR), and 1 INR is equivalent to 0.015 united state dollars and 0.013 Euros (1 USD = 68.50 INR and 1 Euro = 77.39 INR)(12). The current gross domestic product (GDP) of India is 2971.996 Billion USD / 11,468.022 international dollars purchasing power parity(PPP)(13).

Wealth quintile in India is calculated based on consumption goods ( House, television or motorbike or other ) owned by a household and divided into five wealth quintiles of which first is the poorest and fifth is the wealthiest quintile. Percent distribution of the urban and rural population according to wealth quintile is shown in figure 1.

FIGURE 1 PERCENT DIS TR IBUTION OF TH E URBAN A ND RURAL PO PULATION BY WEA LTH QUIN TILE(14)

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CHAPTER 2 PROBLEM STATEMENT, OBJECTIVES, METHODOLOGY:

2.1. PROBLEM STATEMENT:

Human development index(HDI), reflects on the progress of a country in terms of health, education, and income together.

In comparison to neighboring countries like Bhutan, Nepal, Bangladesh, Pakistan, and Sri Lanka, India is only below Sri Lanka in terms of the HDI. It should reflect on better health, education, and income in India in comparison to neighboring countries.

However, comparing health outcome indicators of India with the neighboring countries which are below in rank in terms of HDI, it becomes evident that health outcomes in India are even poor that the neighboring countries as depicted in Table 1.

TABLE 1 HUMAN DEVE LOPMEN T IN DEX, CH ILD MOR TALITY IN DICATORS AND IN C IDENCE O F TUBER CULOS IS IN INDIA AN D NE IGHBOR ING C OUN TR IES; 2016(15)

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Infant mortality and under-five mortality is higher in India in comparison to Bhutan, Nepal, and Bangladesh. Table 1

Despite national programs to control tuberculosis in India, the incidence of tuberculosis is only less than Bangladesh as depicted in Table 1. It reflects on how the efforts of the country to improve health has been failed.

One of the factors which result in poor health outcomes in the country is inadequate access to health care access and poor quality of care(16).

Health care access and quality (HAQ) index, which measures the access and quality of healthcare services, India scored less than neighboring countries like Bangladesh, Nepal, Bhutan(17).

It reflects, as inadequate and disproportionate access to primary and preventive health care services across the wealth quintile, and is one of the factors resulting in poor health outcomes in India(18).

TABLE 2 INSTITUTIONAL DE LIVER Y, ANTENA TAL CAR E AND IMMUN IZA TION AC ROSS THE WEA LTH QUIN TILE IN INDIA(14)

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Households in the lowest wealth quintile are the ones who are deprived of service coverage which become evident by the difference in service coverage indictors like Institutional deliveries, Antenatal care, and Immunization of children across the wealth quintiles(WQ), as depicted in Table 2.

Inadequate service coverage among the lowest WQ also reflects on their health outcomes. Poor in India bear a disproportionately high burden of poor health outcomes as compared to the household in the higher wealth quintile. For instance, Under-five mortality rate, infant mortality rate, neonatal mortality rate, all are high among the households in the lowest wealth quintile as compared to a household in the highest wealth quintile. These inequalities are inversely proportional to wealth, as depicted in Table 3.

TABLE 3 PERCENTAGE DISTR IBUTION O F UN DER-F IVE MORTALITY, IN FANT MO RTA LITY, NE ONATA L MORTA LITY, AC ROSS THE WEA LTH QU IN TILE(14)

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Along with other factors, unaffordable healthcare costs and no available health care facilities are the factors contributing to inadequate access to health care services. For instance, high costs(23%), facility too far (18%) are reason the given for not using antenatal care. Similarly, high costs(16%), facilities to far (18%) are the reason given for no institutional birth.

Money incurred to fulfill medical needs by an individual is not only a user fee which is paid at the time of service but also includes travel cost, time spent on waiting at the expense of absence from the work.

Irrespective of the socio-economic status, all these costs together affect the behavior of the user and reflect on his decision to access health care services(19).

The extent of out-of-pocket expenditure(OOPE) is an indicator of financial protection against unseen health expenditures(20). In the financial year, 2015-16 OOPE estimated 60.59% of Total Health Expenditure, indicating 60.59% of total health expenditure was done by a household at the point of receiving health services and reflects on financial protection towards health care payment.

The share of OOPE in healthcare spending determines the extent of catastrophic health expenditure (CHE) and impoverishment due to health expenditure and impacts on behavior utilize healthcare services if needed due to financial hardship(21).

Borrowing and sale of assets are sources of OOPE for health care spending across all WQ. However, borrowing and sale of asset as a sources of OOPE is more common among rural population as compare to their urban counterparts, as depicted in table 4.

TABLE 4 PERCENT O F HOUSEH OLD RE POR TING AS A SOURCE OF F INANCE F OR MEE TING TH E MEDICAL EXPENDITURE FRO M A R URA L AND URBAN AREA FROM DIFFE RENT WEA LT H QUIN TILE 2015-16(7)

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Financial hardship also affects the ability to access health care facilities; In 2015-16, 25% of the India families identified insufficient money as a factor for not going to any health care facilities for their medical needs(14).

Besides medical cost, nonmedical costs incurred on transportation and time spent on waiting at the expense of absence from the work also prevent a household from seeking needed health care services(22). For instance, poor perceived quality of care by the patient (48%), followed by no nearby government facilities (45%) and long waiting time (41%) are factors for not using public healthcare facilities(23). It also influences their Affordability to Healthcare services and increases out of the pocket expenditure (24).

2.2. JUSTIFICATION:

For equity in access to health services, it is essential to establish a health financing system that enables access to quality health care at an affordable cost(32).

A number of studies are done at the state level to identify bottlenecks of health financing in India, but the finding of those studies cannot be generalized for the country. However, few studies are done at the country level are before 2015, so the use of these studies is limited as a recent fourth report by national family health survey, 2015-16 has shown changed scenario in health and healthcare function since 2005-06, and the result of those studies might be outdated.

Indian is aiming for universal health coverage by 2030, for which new innovative strategies in the health policies are required.

Any change in the health financing strategy depends on negotiation and political will. However, it is worthy of analyzing existing health financing system to find out flaws so that appropriate measures can be taken and move towards universal coverage

This study, therefore, tries to find the bottleneck in current health financing in India.

2.3. OBJECTIVES:

2.3.1. GENERAL OBJECTIVES:

To do performance analyses of the health financing system and explore bottlenecks affecting financial accessibility to health care services, and to make necessary recommendations to relevant stakeholders.

2.3.1. SPECIFIC OBJECTIVES:

I. To analyze the performance and challenges in the existing mechanism of resource collection affecting financial accessibility.
II. To analyze the performance and challenges in existing mechanism pooling affecting financial accessibility.
III. To analyze the performance and challenges in the existing mechanism of purchasing, affecting financial accessibility.
IV. To make recommendations to appropriate stakeholders about the measures to strengthen health financing functions to improve financial accessibility.

2.4. METHODOLOGY:

This study is a literature review, and an analysis of works of literature on health financing and health financing systems in India is done. However, to analyze the performance of health financing functions desk study is done.

2.5. STRATEGY:

To search for peer-reviewed articles, I used Google scholar, pub med, Cochrane library, and Vrije University (VU) library. Snowballing was done form journals, newspaper articles, published reports to find out relevant information for the objectives.

The constitution of India was referred to find out the institutional design of the health system in India.

Online databases of relevant agencies such as The World Bank, World Health Organization, Indian Ministry of Health and family welfare, National Institute for Transforming India (NITI) Aayog, Planning Commission of India, Comptroller and Auditor General (CAG)of India. National Health Account (NHA), National Family Health Survey (NFHS) are all reviewed to obtain policies, programs, and statistic reports..

Keywords used to find literature and grey article are tabulated in Table 7. However, besides Keywords, boolean operations like “AND,” “OR” were used.

2.6. EXCLUSION CRITERIA:

Literature and data available in a language other than English are not included because of the language barrier. However, all the relevant information available in the Hindi language is included from its officially translated English script. Article published before the year 2005 is not included to avoid obsolete information.

2.7. FRAMEWORK:

Despite other frameworks available to analyze the health financing system, OASIS analytical framework, as seen in figure 2, proposed by Mathauer and Carrinis(25) is chosen because OASIS framework guides to identify strength and weakness of health financing function with performance indicator focusing financial accessibility as one of the goals of health financing function.

FIGURE2 INS TITUTIONA L AND O RGANIZA TIONA L A SSESSMENT FOR IMP ROV EMEN T AND STRENGTHEN ING HEALTH F INAN C ING(OAS IS) ANALYTICA L FRAMEWO RK (25)

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The framework analyzes the stewardship function of the ministry of health and guides how three health financing functions: resource collection, pooling, purchasing, are shaped.

Further, nine performance indicators reflect on how well three health financing objectives: sufficient and sustainable resource generation, financial accessibility and optimal use of resources of health financing function followed by health financing policy goal: universal health coverage and ultimate health system goal: improved and equitable outcome.

However, to meet the objective of the study, only health financing performance indicators related to financial accessibility were analyzed, as tabulated in Table 5.

In this framework, most of the performance indicators apply to more than one health financing functions. However, in the context of this study, all three health financing functions will be analyzed by specific performance indicators with their Operationalizations, as depicted in Table 5 and Table 6.

TABLE 5 HEALTH FINANCING FUN C TION W ITH THE IR PERFOR MANCE IN DICA TOR(25)

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Each performance indicator relevant to financial accessibility will be analyzed by the key financial indicator tabulated in Table 6. However, besides the performance indicator of health financing function, the health system and stewardship function will be overviewed by the points mentioned in Table 6.

Financial indicators looked at are suggested by the author of the framework; however, any relevant finding not suggested by the author will be included in the findings and will be discussed in the discussion section.

TABLE 6 OPERATIONA LIZATION OF EACH IN DICATO R (25)

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2.8. KEYWORDS:

Keywords used to search literature are tabulated in Table 7.

TABLE 7 HEALTH FINANCING FUNC TION W ITH KE YWO RDS USE D

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2.9. LIMITATIONS:

The study does not focus on a particular state or district in India, so there is a possibility that some state/ district-specific issues might not have covered.

Available data on health expenditure in India from the data source National Health Account and the World Health Organization(WHO) database are not the same.

The national health account present estimates in decimal where WHO presents in round figures. However, for inter-state comparison, the National health account is followed, whereas the country comparison WHO database is supported.

The national health account and WHO both present data up to the financial year 2015-16, so the amount estimates of health expenditure presented in this study are from 2015-16, which might be different from 2018-19 estimates.

This study does not analyze private health care providers and health insurance schemes, and only focus on public health care providers. However, data available from different state health insurance schemes in India were included.

This paper only included literature published in English and had free access. So the possibility of exclusion of some relevant study results cannot be denied.

However, all the government official documents found relevant to the study are included with its English version, made available by the government of India.

CHAPTER 3 STUDY RESULTS FINDINGS

This chapter will look at the health system overview, stewardship function in the health system, and analyze health financing function(Resource collection, Pooling, Purchasing) with their Operationalizations .

To explore the stewardship function, institutional design and organizational structure of the Health care system in India. This subsection is organized as follow.

3.1. Gross domestic product (GDP) growth rates
3.2. Actors involved in stewardship functions
3.3. Healthcare system, service delivery and infrastructure
3.4. Human resources for health
3.5. The legal and regulatory framework for health financing
3.6. Key actors in health financing
3.7. Health Expenditure in India
3.8. Resource collection
3.9. Pooling
3.10. Purchasing

3.1. GROSS DOMESTIC PRODUCT (GDP) GROWTH RATES:

Indian is the seventh-large economy in the world in terms of GDP(26). In 2018 estimated GDP of India was 2.7 trillion international united state dollars (INR 187.7 million) with the annual growth rate of 6.9% (27). However, by looking at per-capita GDP in terms of purchasing power parity, India ranks 119 among the countries in the world and is even below then neighboring countries like Bhutan and Sri Lanka(28). In comparison to the annual growth rate of GDP, per capita, the annual growth rate is 5.8%(28).

3.2. ACTORS INVOLVED IN STEWARDSHIP FUNCTIONS:

By the mandate of the constitution of India article 47, the state government is accountable for offering health care services as per the guidelines of Indian public health standards(5). However, governance and administration of the healthcare system in India are provided by both union and state government as per the seventh Indian constitutional schedule(29) (5). For instance, Union government is responsible for national disease-specific programs (National AIDS Control Programme, Revised National Tuberculosis Programme, National Non-Communicable Disease Programme, Janani Shishu Suraksha Karyakram, National Health Mission to mention a few) aimed to stop and control communicable and non- communicable diseases, enhancing maternity and child health. However, maintaining public health, hospitals, sanitation, nutrition is the duty of state government.

Both (union and state) governments collectively control quality in drug manufacturing, medical education, population control programs, and programs to ensure economic safety against invisible medical expenses and food adulteration avoidance.

3.3. HEALTHCARE SYSTEM, SERVICE DELIVERY AND INFRASTRUCTURE:

3.3.1. HEALTH CARE SYSTEM:

A health system is an organization whose main objective is to enhance health and health equity through the most effective use of accessible resources in financially fair and responsive ways and primary actions intended to promote, restore or maintain health(30).

India has seven health systems, namely Allopathic and AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy), which are legally acknowledged and practiced to fulfill the health care needs of countrymen(31).

Governance and administration of Allopathic and AYUSH are done by different ministries, departments, and councils.

The allopathic health system, for instance, is under the ministry of health and family welfare. However, AYUSH is governed and administered by the ministry of AYUSH(32).

3.3.2. SERVICE DELIVERY:

To achieve this goal, India has organized a three-tiered health-care system for preventive and curative health care needs and categorized as primary, secondary, and tertiary health care systems (34). Public and private healthcare providers give health care services in rural and urban areas(33).

The primary health care system is the first contact point between patient and healthcare system responsible for providing primary care through sub centers (SC) the first point of contact between community and health services(35) and primary health care centers(PHC) responsible for providing integrated curative and preventive health care services (36).

The second tier of the health system is designed to provide care to patients referred from primary health care in need of specialist care the second tier of the health system in India includes district hospitals, sub-district hospitals, and community health center at the block level(33). Five thousand six hundred twenty-four community health centers, 12000 sub- district hospitals, and 605 district hospitals are functioning across India(7).

The third tier of the health system offers services such as specialized intensive care units, advanced diagnostic support services, and specialized consultative care to a patient referred from primary and secondary medical care. Medical colleges and research institutes provide the third tire of the health care system(33).

Private healthcare providers ranging from multi-specialty corporate hospitals to private clinics and solo medical practitioners, including registered medical practitioners and informal healthcare providers( healers without a valid medical license) are part of the private healthcare industry in India(37). Private healthcare provider primarily provide secondary and tertiary care(38)

3.3.3. HEALTH CARE INFRASTRUCTURE:

Health care infrastructure reflects on the commitment of the government to ensure the necessary support for the delivery of public health activities(39).

The country has total 1,56,231 sub-centers(23), 25,650 PHCs, 476 medical colleges, 562 dental colleges, 3,215 institutions for general nurse midwives courses, and 777 colleges for pharmaceutical studies.

All together public facilities have 7,10,761 total number of hospital beds in the country of which 19,810 public hospitals are in a rural area offering 2,79,588 beds, and 3,772 public hospitals are in the urban area with 43,1,173 beds. Also, dispensaries (27,698 total in number) and hospitals (3,943 total in number) are delivering their services under AYUSH management status (7).

3.4. HUMAN RESOURCES FOR HEALTH:

Human resource for health is one of the vital pillars of the healthcare system and to ensure the effective functioning of healthcare facilities; it is essential to have an adequate skill mix human resource for health.

Across the country number of allopathic practicing, doctors are 1.4 million, whereas doctors practicing AYUSH all together are 773668. Also dental (251207), auxiliary nurse midwives(ANM) (841,279), registered nurses & registered midwives(1,980,536 ), lady health visitors (56,367) and pharmacist (907,132) work across the country(7).

Among the AYUSH practicing doctors number of doctors practicing Ayurveda is more as compared to the rest of the counterpart, as shown in figure 3.

FIGURE 3 PERCEN TAGE OF REG IS TERE D AYUSH DOC TORS IN INDIA(7)

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The distribution of health care facilities and human resources for health varies across the state, and their numbers are associated with state government spending on health care.

The general government health expenditure(GGHE) of state Assam is 7.5% of general government expenditure (GGE), and on average one allopathic doctor is present over the population of 539 people and one government hospital bed serves 1914 people whereas in Bihar GGHE is 4.4% of GGE, and one allopathic doctor is present over the population of 28,391 and one bed is available for the population of 5654 which is far more in comparison to Assam (Table 8). World Health Organization(WHO) has recommended one doctor per 1000 population(40). However, in Indian states, this ratio far low in comparison to the recommended ratio.

TABLE 8 FINANCING IN DICA TORS AN D PUB LIC HEA LTH SERVICES (7)

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Inadequate numbers of medical staff and health care facilities affect the utilization of public facilities. For instance, in Assam, 30% of households who do not use public healthcare facilities gave poor quality of care as a reason whereas in Bihar, 59% said so, as seen in Table 8.

This also can be seen as these people are forced towards expensive private health care providers, which may become a barrier to access needed health care services due to financial hardship. It is also a violation of the right to access health care services.

Health care services in private facilities are expensive as compared to public facilities. For instance, in 2014, estimated total expenditure on per childbirth in public facilities in the rural area( INR 1587/ 23 USD) and urban area(INR 2217/30 USD). However, in private facilities, it was estimated at rural (INR 14778/214 USD) and in urban (INR 20238/ 293 USD)(7)

Despite private health facilities are expensive compared to public facilities, services of private facilities are preferred over public health facilities, across the rural-urban population and lowest, fourth and highest wealth quintiles. However, a household in second and middle wealth quintiles use public facilities for their health care needs, as depicted in Table 9.

TABLE 9 SOURCE OF HEA LTH CARE PR OV IDER ACROS S THE WEALTH IN DEX AND R UR AL-URBAN AREA(14)

Abbildung in dieser Leseprobe nicht enthalten

To look at the possible cause for Inter-state disparity in spending on health, it is important to look at the legal and regulatory framework and identify why this disparity exists.

3.5. LEGAL AND REGULATORY FRAMEWORK FOR HEALTH FINANCING:

Health financing is an arrangement by which financial resources for health are mobilized, accumulated, and utilized within the health system, to provide needed health care services to people without financial hardship(41).

Health care financing models countries follow to manage the healthcare system can be categories as follow.

Bismarck Model: Named after Otto von Bismarck, first chancellor of the German empire who invented this model(42). In this model of financing, the healthcare system is financed by the compulsory contribution of employer and employee to employer insurance fund and managed by nonprofit agencies, for those who are not covered by employ insurance funds are covered by public funds. This system is also known as social health insurance(41).

Beveridge System: named after Lord William Beveridge(41), who designed National Health Services in Britain, this model uses tax money to finance the healthcare system to provide needed healthcare to all citizens(43).

Mixed Model: In this model with an element of Bismark ( tax money) and Beveridge models (compulsory employer-employee contribution), private funding by voluntary health insurance also has a significant contribution to finance health care system(44).

In India, the healthcare financing system is a combination of all these models. As for government employees’, the Bismarck model is in place, schemes like the central government health scheme(CGHS) covering union government employee and ex-employees (including their dependents) (45). Whereas state government schemes, employ state insurance scheme(ESIC) covering employees (including their dependents)working in organizations registered under factories act are in place(46).

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