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HEAL6010 Organisation Of Health Care Systems

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Course Code: HEAL6010
University: Curtin University

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Country: Australia

Question:
Write about the Essay for Equity in Healthcare.
 
Answer:

Introduction
The health has been recognised as a fundamental human right. The citizens of any country have a basic human right to be free from illness/ disease and lead socially and economically productive lives with complete physical, mental, social and spiritual well-being. Health equity means that all the citizens of a country will be taken care of their health needs and it is the responsibility of state to provide accessible, affordable and quality health services to its citizens.
The concerns for health equity were first raised during Alma-Ata-Declaration of World Health Organisation. The inequitable access to healthcare services and increased out-of-pocket expenditures for seeking healthcare is a major challenge in low and middle income countries (Dwivedi, & Pradhan 2017). The researchers have estimated that globally approximately 1.3 billion individuals are deprived of access to an equitable and affordable healthcare service (Leive, & Xu 2008). Also on an average, households spend approximately forty percent of their income to treat their ill-health (Akazili et al, 2012).
Equitable financial arrangements in health-care delivery are very important for achieving Universal Health Care. It is important to raise financial resources to overcome financial risks and barriers to universal health care; and also to provide equitable and efficient health services (Kutzin, 2013). In addition, healthcare reforms that promote equity in the distribution of financial resources may also increase utilisation of healthcare services (ibid). Equitable resource allocation may also require purchasing of resources from external sources or pooling of resources (McIntyre, & Kutzin 2012).
The governments should assure equitable distribution of resources. It is important to maintain horizontal equity as well as vertical equity while distributing health and financial resources. It means the individuals or areas with same needs must get same amount of resources and individuals or areas with more needs must get more amount of resources (McIntyre, & Kutzin 2012). For this, it becomes important to access health needs of populations across levels of care (Primary, Secondary, Tertiary) as well as across geographical areas (Anselmi, Lagarde, & Hanson, 2015). Further it becomes important to monitor health utilisation rates (ibid). 
 
Health Services system in India and Health Equity 
Healthcare system of India is a mix of public and private health services. Public health services system is a three tier system with primary health centres at the peripheral level with some basic health facilities. Secondary level of system comprises CHC (Community Health Centres), and district hospitals. Tertiary level of system comprises tertiary care institutions and apex institutions like AIIMS (All India Institute of Medical Sciences). Inspite of such a good architectural arrangement of health services system, the system is mostly dilapidated and public have to spend out-of-pocket to avail health services from private practitioners (Ruhil, 2015). For the first level of contact between community and health services system, the country has a chain of community health workers called ‘ASHA’. These are interface between people at community level and health services system. Primary care is provided at PHCs and patients are referred to CHCs for further treatment. There is one CHC over a population of 80,000 to 1,20,000. There is one surgeon, one physician, one gynaecologist and one anaesthetist at CHC level. For specialised treatment patients are further referred to district hospital which is one in each block or district. The patients which cannot be managed at secondary level are referred to apex institutes.
India as a country needs special efforts to create equitable access to health-care services as majority of its pre-mature deaths happen from preventable causes (Joumard, & Kumar 2015). Government of India needs to scale-up its public health-care spending with more number of professionals in public health services and improving the overall primary healthcare services system (ibid). In the absence of robust public health services system in the country, the out-of-pocket expenditure for health-care is more in the country and public have to largely rely on private health services. The country currently spends 5 percent of GDP on healthcare; out of which 4 percent is private expenditure or out-of-pocket expenditure and only 1 percent is government spending (ibid). The government needs to increase financial allocation to public healthcare and needs to strengthen its health services system to make it more equitable.
 
Many sources of financing health-care services include taxation, social security schemes, health insurance and levying user charges (Amakom, & Ezenekwe 2012). In India social security schemes are not robust enough to protect the citizens from the catastrophe of major health illnesses in the family (Dwivedi, & Pradhan 2017). Health inequities are widely prevalent in the country and those who are most needful of healthcare services are most disadvantaged one in terms of access to healthcare services (ibid). Researchers have shown that there are regional disparities among various states of India, in healthcare spending (ibid). The states which are relatively backward and are most in need of healthcare financing have paradoxically least expenditures on health (ibid). It is imperative to reduce the burden of out-of-pocket health expenditures and provide equitable healthcare financing in India.
India is currently facing huge health problems. India has high Infant mortality rates (IMR), Under-5 mortality rates (U5MR), and maternal mortality rates (MMR). Also the children who are born, majority have low birth weight (Drèze, & Sen, 2013). Among children nutritional deficiencies are high resulting in malnutrition and thus physical and mental retardation (ibid). The problems also have social roots where women have comparatively low social status and are treated as sub-ordinate to men. The women even if pregnant eat at last after serving food to all male members of family. The earning male members of family and elderly are given priority rather than women and children (ibid). The breastfeeding rates are also very low. The poor women do not secrete sufficient milk due to their own poor health status. Also women are busy in work; either earning or in household work; and thus do not get time and space to breastfeed their children frequently.
The country also faces double burden of diseases where communicable diseases are still prevalent and new chronic life-style related problems such as cardio-vascular diseases, cancers and chronic respiratory diseases are adding to the burden (Patel et al, 2011). Tobacco use is also highly prevalent in India with about one-third of Indian population using tobacco (IIPS & MoHFW 2009-10). Tobacco is a major risk factor for majority of communicable and non-communicable diseases including adverse reproductive outcomes. Also the problems of outdoor air pollution and indoor air pollution are high leading to heart diseases and respiratory diseases (IHME, 2013).
The problem of open defaecation is also prevalent in rural villages of India and so the prevalence of diarrhoea and cholera especially in children (Spears, & Lamba, 2013). The “Swachcha Bharat Abhiyaan” (Clean India Campaign) was started by govt. of India in October 2014; under which government is providing help for the construction of latrines. The aim of the campaign is to make India open defaecation free. The programme is getting wide appreciation. People are actively participating in making their villages, streets and cities clean.
 
According to a study only 16 percent of population had any free access to public healthcare (Kumar et al, 2011). In few states like Tamilnadu and Kerala, the performance of public health services was satisfactory but in some other states like Bihar, Jharkhand, U.P.; the services provided by public healthcare system were NOT satisfactory (ibid). Distance of health-care facility from home, and total non-availability of health service at the designated point of primary health care were main reasons for dissatisfaction among public (Kumar et al, 2011). One report by Government itself reported that about 10 percent of PHCs (Primary Health Centres) do not have a physical presence of doctor (MoHFW, 2012). Also 37 percent of PHCs are without a physical presence of lab-technician and about 25 percent of PHCs did not have a pharmacist (ibid). Thus management of human resource for health is a huge challenge while providing equitable health services.
In rural areas of India, access to healthcare is a major problem. Private practitioners do not want to practice in rural areas due to lack of lifestyle facilities in those areas. Thus majority of the time public health facilities are the only means of getting healthcare in rural areas. The PHCs in rural areas are shut most of the time and are without basic facilities like a qualified doctor, lab-technician, pharmacist, essential medicines, first-aid facilities, emergency services etc. (MoHFW, 2012). Similar is the state of urban slums. Majority of the health facilities are concentrated in urban city centres, including both the private facilities as well as government facilities.
Taking advantage of dilapidated health services system in the country, corporate hospitals are mushrooming which are making profits from medical tourism instead of treating their own countrymen. A research reported that in 2012, India treated 0.2 million foreign patients which gave a revenue of USD 2 billion (Sachan, 2013). The private sector in India is largely unregulated. Although Clinical Establishments Act 2010 set some norms for private hospitals but its implementation is rather lethargic (ibid). Quereshi committee report revealed that these corporate hospitals have taken free land from government and still are not fulfilling basic conditions of treating a certain number of BPL patients for free of cost. Also the quality of treatment provided to free patients is very poor.
Another important component of Indian Health Services System is Medical Pluralism (Ruhil, 2015). It includes coded as well as non-coded traditional systems of medicine (ibid). The coded systems of medicine include AYUSH (Ayurveda, Yoga, Unani, Siddha, Sowa-Rigpa, Homeopathy). The government of India has integrated these systems of medicine into mainstream state health services (ibid). The national health policy of 2017 has also recognised the importance of traditional medicine (Government of India, 2017). Government of India also celebrate ‘International Day of Yoga’ each year on 21 June, which has made Guinnes World Record in 2015 with 35,985 people and 84 nations participated in it (Ruhil, 2015). At the level of CHC and district hospital a separate department of AYUSH has been created which recruit the AYUSH qualified health practitioners to provide its services.
 
The government has also started some public insurance schemes like Rashtriya Swasthya Bima Yojana; but the effectiveness of these schemes is questionable and has been critically analysed by many researchers (Selvaraj, & Karan, 2012). The other insurance schemes include Employee State Insurance Scheme (ESIS), Central Government Health Scheme (CGHS), Aarogyasri in Andhra-Pradesh, and Yeshaswini in Karnataka. The out-of-pocket expenditures are high and patients have to seek private facilities for diagnostics, x-rays, MRI, Ultrasound, laboratory diagnosis, and medicines as these facilities are lacking in public health facilities (ibid). Quality of care is also compromised in public health facilities (ibid). There are also differentials in quality of care given to government insured patients in private hospitals as compared to highly paid patients and NRI patients (ibid).
Informal payments and use of influence to get treatment is also highly prevalent in public health facilities (Rao et al, 2009). There is always a large queue at public health facilities and then there are some influential people who get patronage over others. Also the people come out of cars with BPL (Below Poverty Line) cards to avail free services. This snatch the benefits from those people who are actually poor but could not get BPL card due to lack of contacts and lack of literacy. Thus actual implementation of pro-poor policies is highly inequitable and remains unsuccessful in addressing the issues related to health equity.
The central government give grants to states to run public health services under National Health Mission (NHM) which started as National Rural Health Mission (NRHM) in 2005 and scaled up in 2013 to include urban areas as well. The NRHM further have several health schemes like, ‘Janani Suraksha Yojana’ which is a conditional cash transfer scheme. The certain amount of money is transferred in to the accounts of pregnant mothers to take care of themselves and their new-borns (Joumard, & Kumar, 2015).
The proper management of human resource for health is also a great challenge (Rao et al, 2012). There is increased commercialisation of medical education in India with so many private players entering into it, producing a huge number of medical graduates each year who remain unabsorbed in to the mainstream health system and end up working on their own private clinic and the problem of health inequity remain unanswered (ibid). 
Conclusion
The India as a country is in very advantageous position strategically with its economy among the fastest growing economies of the world and majority of its population young and productive i.e. below 35 years of age and ready to harness the benefits of demographic dividend. In such a scenario, achieving health equity is not a distant dream but requires political will, greater proportion of GDP to be spent to strengthen public health services system, maintaining quality standards in medical education and proper absorption of medical graduates passing each year from hundreds of medical colleges in the country. The social security schemes need to be formulated and implemented in such a way that its benefits reach the real poor and help address the problems of inequity especially health inequities in society.
 
References 
Akazili, J., Garshong, B., Aikins, M., Gyapong, J., & McIntyre, D. (2012). Progressivity of health care financing and incidence of service benefits in Ghana. Health Policy Planning, 27(1), i13–22.
Amakom, U., & Ezenekwe, U. (2012). Implications of households catastrophic out of pocket (OOP) healthcare spending in Nigeria. J Res Econ Int Finance (JREIF), 1(5), 136–40.
Anselmi, L., Lagarde, M., & Hanson, K. (2015). Equity in the allocation of public sector financial resources in low- and middle-income countries: a systematic literature review. Health Policy and Planning, 30, 528–545. doi:10.1093/heapol/czu034.
Drèze, J., & Sen, A. (2013). An Uncertain Glory – India and its Contradictions, Princeton Press.
Dwivedi, R., & Pradhan, J. (2017). Does equity in healthcare spending exist among Indian states? Explaining regional variations from national sample survey data. International Journal for Equity in Health, 16, 15. DOI 10.1186/s12939-017-0517-y.
Government of India. National Health Policy 2017. Policy document, MoHFW 2017, New Delhi.
Institute for Health Metrics and Evaulation, IHME (2013), Global Burden of Disease 2010, Released March 2013, www.healthmetricsandevaluation.org/gbd.
International Institute for Population Sciences (IIPS), Mumbai and Ministry of Health and Family Welfare (MoHFW). Government of India: Global Adult Tobacco Survey (GATS) – India, 2009-10. New Delhi: MoHFW, Govt. of India; 2010. ISBN 978-81-920192-0-8.  Available from: https://mohfw.nic.in/WriteReadData/l892s/1455618937GATS%20India.pdf. last accessed 5 January 2016.
Joumard, I., & Kumar, A. (2015). Improving Health Outcomes and Health Care in India. OECD Economics Department Working Papers, No. 1184, OECD Publishing. https://dx.doi.org/10.1787/5js7t9ptcr26-en.
Kumar, A., Chen, L., Choudhury, M., Ganju, S., Mahajan, V., Sinha, A., & Abhijit, S. (2011). Financing Health Care for All: Challenges and Opportunities. Lancet, 377, 668–79.
Kutzin, J. ( 2013). Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization, 91, 602–11.
Leive, A., & Xu, K. (2008). Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bull World Health Organ, 86(11), 849–856C.
McIntyre, D., Kutzin, J. (2012). Revenue collection and pooling arrangements in financing. In: Smith RD, Hanson K (eds). Health Systems in Low and Middle Income Countries: An Economic and Policy Perspective. New York: Oxford University Press, pp. 77–102.
MoHFW (2012), Rural Health Statistics in India 2012, Statistics Division, Ministry of Health and Family Welfare, Government of India, March.
Patel, V., Chatterji, S., Chisholm, D., Ebrahim, S., Gopalakrishna, G., Mathers, C., Mohan, V., Prabhakaran, D., Ravindran, R., & Reddy, K. (2011). Chronic diseases and injuries in India. Lancet, 377(9763), 413-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21227486. [18 April 2017]
Rao, K., Bhatnagar, A., & Berman, P. (2012). So many, yet few: Human resources for health in India. Human Resources for Health, 10, 19.
Rao, K., Saran, I., & Srivastava, A. (2009). The Inequity of Informal Payments for Health Care in India. India Health Beat, 2(1), World Bank/Public Health Foundation of India.
Ruhil, R. (2015). Medical Pluralism in India and its Integration into State Health Services System. AYUSHDHARA, 2(5), 309-314.
Ruhil, R. (2015). The Roots of “Brown Sahib Medical Men’s” Burden. Indian J Comm Health, 27(4), 429-434.
Sachan, D. (2013). Tackling corruption in Indian Medicine. Lancet, 382(9905), e23 – e24.
Selvaraj, S., & Karan, A. K. (2012). Why publicly financed health insurance schemes are ineffective in providing financial risk protection. Economic & Political Weekly, 47(11), 60-68.
Spears, D., & Lamba, S. (2013). Effects of Early-Life Exposure to Sanitation on Childhood Cognitive Skills: Evidence from India’s Total Sanitation Campaign. Policy Research Working Paper 6659, World Bank Sustainable Development Network, World Bank Publishing.

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