Loksatta's Roadmap to Universal Healthcare

Without health nothing is of any
use, not money nor anything else
Democritus in his book On Diet
2
”
“

Contents
1. Growing Population – Growing Challenges
2. Progress so far
3. Avoidable Suffering
4. Increasing Burden of Non-Communicable Diseases
5. System Failures
A. Budget Allocations
B. Public Health Facilities –Shortages
C. Dependence on Private Providers
D. Impact of Out of Pocket Expenditure (OOPE)
E. Poor Health Record Keeping
6. The Global Experience
7. Reform Agenda
8. Framework for Universal Healthcare Model
9. Health Sector Can Create Jobs !
10. Issues to be resolved
11. Annexures
3

Growing Population – Growing Challenges
A Decade of Tracking Progress for Maternal, Newborn and Child Survival, The 2015 Report
*World Bank -data.worldbank.org
** WHO,2015
The Financial Express – Jan 21st,2015
The population is set to rise to
1.4 billion by 2026 (Annex 1)
Demographics
Total Population(000) 1,311,051
Total under-five Population(000) 123,711
Births (000) 25,794
Total under-five deaths(000) 1,201
Neonatal Deaths (% of under-five deaths)) 58
Neonatal Mortality Rate (per 1000 live births) 28
Infant Mortality Rate (per 1000 live births) 38
Maternal Mortality Rate(2014)(per 1,00,000
live births)
181*
Total maternal deaths 45,000**
Adolescent birth rate (per 1000 girls) 26
Total Fertility Rate (per woman) 2.4
4

Progress so far…
The Hindu- May 14th,2015
5

National Health Profile, 2015
6

GDP (PPP) Per Capita ($)
Sources:
World Bank Data 2015
10
15
20
25
30
35
40
45
50
0 2,000 4,000 6,000 8,000
India
Kyrgyzstan
Zimbabwe
Vietnam
Bangladesh
Nepal
Papua New
Guinea
Tajikistan
Philippines
Infant Mortality Rate
A lot to learn from the neighbours –
Bangladesh and Nepal have lower IMR
7

Sources:
1. Estimates of National Vector Borne Disease Program,2014
2. Balarajan, Y., Selvaraj, S. and Subramanian, S. (2011) healthcare
and equity in India,TheLancet,377, 505;
3. Global TB control, WHO 2015
4. World Bank Data, 2012
5. Unicef: Rapid Survey of children 2013-14 (Annex 2)
Avoidable Suffering!
1.2 million under-five
year old children died in
2015
Total annual cases of
9.7 million malaria
infections
2.5 million new cases of
Tuberculosis in 2015
Out of pocket (OOP)
expenditure for health
forces 55 million people
below the poverty line
28% of deaths are
caused by mostly
preventable
communicable diseases
and maternal, perinatal
and nutritional diseases
Only 65.2% of the
children aged between
1-2 years are fully
immunised
8

An increasing Non Communicable Disease (NCD) burden!
Sources: Healthcare: The neglected GDP driver by KPMG- September 2015, page- 16
.
9

Economic Burden!
10

Effects on Labour Productivity….
11

System Failures
Illness is neither an indulgence for
which people have to pay, nor an
offence for which they should be
penalised, but a misfortune, the cost
of which should be shared by the
community.
“
”Aneurin Bevan, Architect of National Health Service (United Kingdom)
12

Critical Issues and Challenges
Doctors accessibility in rural
healthcare
Unaffordable family care to
the people
Inefficient public-private
partnerships
Accountability in public
healthcare
High out-of-pocket health
expenditure
Low public health
expenditure share
Decline in family care – over-
specialization
Alternative systems –
integration
13

Budget
Allocations
Public health expenditure
is roughly 1.3% of our GDP.
Out of which currently
around 1.05% is spent by
the state governments
14
Source: Connecting the Dots – An Analysis of the Union Budget 2016-17,Center for Budget and Governance Accountability(CBGA)

The public health expenditure of India is one of the lowest in the world and it needs
to be increased to atleast 2.5% of our GDP
Livemint – Dec 15th,2015
Public Heath Expenditures in Select Countries
18

In India too, While increasing the health expenditures,
the Union and States expenditures ratio should rise to 1:1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
USA Australia Brazil India
Share of Federal and State health
expenditures in select countires
Federal States
In countries such as USA, Australia and Brazil, the
federal governments health expenditure is almost 50%
of the total public health expenditure
The share of the Union government allocations out of
total public expenditure has been decreasing. The
current ratio of Union and States expenditures is 1:4.
Health Public Expenditure: Share of Center and States
19
Source: Connecting the Dots – An Analysis of the Union Budget 2016-
17,Center for Budget and Governance Accountability(CBGA)

Public Health Facilities - Shortages
Shortage of PHC’s and CHC’s in different states
(Annex 7 & 8)
Norm
Hilly/tribal/ desert
areas
(Population)
Plain areas
(Population)
PHC 20,000 30,000
CHC 80,000 1,20,000
Currently, India has 1 PHC for every
50,000(approx.) population and 1 CHC for
every 2,30,000(approx.) population
While the norm is..
Shortfalls(%) in PHC’s and CHC’s
20
Planning Commission of India

Dependence on private providers
As per the National Family Health Survey(NFHS-3),
only 34.4% of the people used public health
facilities when they fell sick.
Around 65% of the people did not use the public
healthcare facilities due to various reasons.
The widely reported reasons were
a. Poor quality care (57%)
b. No nearby facility (48%)
c. Waiting time is too long (24%)
(Annex 4 & 5)
This eventually led to heavy dependence on private healthcare facilities, increasing the costs. (Annex 6)
41.9
32
58.1
68
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rural Urban
Percentage distribution of hospitalised
cases
Public Hospitals Private Hospitals
Source: NSSO report- Key Indicators of Social Consumption
in India: Health, January-June, 2014
21

Around 78% of total health expenditure in
India is private
Rural India
(Average)
14,935
Average Expenditures Per Hospitalization
(Rural)
Livemint- Dec 2nd,2015
22

While the average monthly incomes of an individual
hover around ₹ 7000, the average expenditure per
hospitalization is twice and thrice the incomes in rural
and urban areas respectively (Annex 3)
Urban India
(Average)
24,436
Livemint- Dec 2nd,2015
Average Expenditures Per Hospitalization
(Urban) 23

 Out-of-Pocket expenditure in India is 86%* of total
private health expenditure
 Of the households that descent into poverty more
than 50% are due to ill-health and Healthcare
expenditures**.
Source:
*http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS
**Balarajan, Y., Selvaraj, S. and Subramanian, S. (2011) healthcare and equity in
India,TheLancet,377, 505;
***Assuring health coverage for all in India – Lancet , December 2015
Impact of Out-of-Pocket Expenditure (OOPE)
 Hospitalized Indians spend 48% of total annual
expenditures/savings on healthcare.
 Hospitalized Indians draw more than 33% of hospitalization
expenses by borrowing money or selling assets.
 While the Compound Annual Growth Rate(CAGR) in outpatient
care is same for both public and private hospitals(9.5%), the
CAGR in inpatient care is higher for private(11.4%) than
public(5.8%) (Annex 6)***
220 319
554
788
OUTPATIENTS (PUBLIC HOSPITALS) OUT PATIENTS (PRIVATE
HOSPITALS)
OOP expenditure incurred by
Outpatients
2004 2014
4733
8804
6120
25850
INPATIENTS (PUBLIC HOSPITALS) INPATIENTS (PRIVATE HOSPITALS)
OOP expenditure incurred
by Inpatients
2004 2014
24

Poor Health Record Keeping
• Lack of robust data collection
mechanisms
• Inadequate information sharing
with different levels of healthcare
providers
• Many of the epidemics cannot
be prevented without knowing
the source of such maladies
As a result, preventive health care is undermined
26

BROAD FEATURES
Healthcare Models in various countries
Great Britain, Spain,
Scandinavia, New
Zealand, Hong Kong
Germany, France
Belgium, Netherlands,
Japan, Switzerland,
Latin America
Canada,
Taiwan and
South Korea
Africa, India, China
and South America
United States of
America
• Healthcare is provided
and financed by the govt
through tax payments
• There are no medical bills
• Medical treatment is a
public service
• Providers can be govt
employees
• Lows costs b/c the govt
controls costs as the sole
payer
• This model uses a health
insurance system which is
usually financed by both
employers and employees
through payroll deduction.
• Health insurers are required
to insure everybody and
they are not profit-making
ventures.
• Provides insurance through
competing social funds
• Offers multiple sources of
provision
Bismark Free-MarketOut-of-PocketBeveridge
National Health
Insurance
• Providers are private
• Payer is a government-run
insurance program that
every citizen pays into;
• Has considerable market
power to negotiate lower
prices
• National insurance collects
monthly premiums and pays
medical bills
• Plans tend to be cheaper
and much simpler
administratively than
American-style insurance
• Most medical care is
paid for by the patient,
out-of-pocket
• No Universal Health
Coverage
• Only the rich get
medical care; the poor
stay sick or die
• Maintains safety net through
public payment of premiums
• Offers services and
insurance through private
sector
The United States has a fragmented
system, with different plans for
different populations (i.e.,
government-sponsored Medicare for
those over 65, free care for military
veterans, employer-funded
insurance for those who are working,
private medical insurance for those
who can afford it, and out-of-pocket
care or medical assistance for those
who have no insurance).
28

United
Kingdom
Community Healthcare
1.Primary care services are delivered by a wide variety of providers
including General Practitioners (GPs), dentists, optometrists,
pharmacists, walk-in centres and NHS 111. There are more than
66351 general practitioners in UK providing primary care services
2.Community health services are delivered by foundation and
non-foundation community health trusts. Services include district
nurses, health visitors, school nursing, community specialist services,
hospital at home, NHS walk-in centres and home-based
rehabilitation.
Tertiary Care
Acute trusts provide secondary care and more specialised services. The majority of activity in
acute trusts are commissioned by Clinical Commissioning Groups(CCG). However, some
specialised services are commissioned centrally by NHS.
Accountability
Revalidation is the process by which clinicians have to demonstrate to their regulatory bodies
(for example, General Medical Council and Nursing and Midwifery Council) that they are up
to date and fit to practice. It is a way of regulating the professions and contributing to the
ongoing improvement in the quality of care delivered to patient
Incentives/Performance
Clinical Excellence Awards Scheme, merit pay schemes based on
individual performance; NHS scheme is still attempting to assess
and reward individual performance, when the NHS and many
private sector workplaces rely on the activities of teams.
Health Information Data
The Health and Social Care Information Centre (HSCIC) was formed
in April 2013 as an executive, non-departmental public body and
the national provider of information, data and IT systems for
patients, service users, clinicians, commissioners, analysts, and
researchers in health and social care base
Drug Supply
Under laws governing the supply of medicines, medicines can be
obtained under three categories:
1.Prescription-only medicines need a prescription issued by a GP
or another suitably qualified healthcare professional. One can
take the prescription to a pharmacy or a dispensing GP surgery to
collect the medicines.
2.Pharmacy medicines are available from a pharmacy without a
prescription, but under the supervision of a pharmacist.
3.General sales list medicines can be bought from pharmacies,
supermarkets and other retail outlets without the supervision of a
pharmacist. These are sometimes referred to as over-the-counter
medicines.
Universal Coverage
National Health Service (NHS) is a public funded healthcare system in all
the four regions of the UK. The NHS is made up of a wide range of
organisations specialising in different types of services for patients.
Together, these services deal with over 1 million patients every 36 hours.
Providers of ‘primary care’ are the first point of contact for physical and
mental health and wellbeing concerns, in non-urgent cases. These
include general practitioners (GPs), but also dentists, opticians, and
pharmacists (for medicines and medical advice)
The money for the NHS comes from the Treasury. Most of the money is
raised through taxation.
Public Expenditure on
Health
as % of GDP (2013)
7.6 IMR/MMR (2015) 4/9 Life Expectancy
(2013)
81
29

Mexico Public Expenditure
on Health
as % of GDP (2013) 3.2
IMR/MMR (2015)
11/38
Life Expectancy
(2013)
77
Primary Care :
Mexican health system is fragmented based on employment status and
respective insurance institutions. Each institution has respective independent
network of primary, secondary and tertiary service providers and necessary
infrastructure. In addition, many pharmacies in Mexico have a doctor on staff or
next door who charges a few dollars for a basic consultation. These pharmacy
clinics continue to grow and provide underserved populations in semi urban and
rural areas with an inexpensive and convenient way to obtain medications.
Tertiary Care :
Hospitals and clinics that provide
medical care for social security recipients
are of variable quality. While major urban
institutions may provide adequate to
excellent tertiary care, rural hospitals
often have outdated equipment, long
waits and inadequate staffing.
Drug Supply :
Although many drugs in Mexico are available over the counter at a
pharmacy, certain prescription drugs in Mexico do require a
prescription from a Mexican pharmacist. Mexicoís social insurance
programmes achieve very significant savings over the retail cost of
medicines through a system on which manufacturers of
interchangeable generics bid for business, designating the price at
which a particular volume of medicines can be offered.
Universal Coverage
Mexico recognises health as a constitutional right and
offers basic levels of universal healthcare. Introduction
of "Seguro Popular" in 2003 was a landmark event
towards universal coverage. In spite of the availability
of basic universal healthcare, approximately 20% of
Mexicans remain uncovered and health equality in
Mexico remains low even for those with healthcare
coverage
Finance
Mexico’s public healthcare sector, which is predominantly funded
by taxes, consists of social security institutions and government-
sponsored healthcare. Each of these public sectors covers
approximately 40% of the Mexican population. The social security
institutions cover private employees, retirees, and their families.
Those who are not eligible for social security have the option to
subscribe to Seguro Popular (SP; Popular Insurance), which is
government-sponsored health insurance.
Health Information Database
Mexico has disjointed data systems and patient registers
to monitor quality and outcomes. To change this, New
Mexico Health Information Collaborative (NMHIC) is
envisaged to provide a statewide Health Information
Exchange (HIE) that allows authorized healthcare
professionals with patient consent to quickly access the
patient’s history in one centralized record.
Accountability
Poor monitoring and evaluation of reforms are
important impediments which led to inefficient
healthcare system.
Incentives for Performance
Affiliation to the Seguro Popular is voluntary, yet the reform includes incentives for expanding coverage. States
have an incentive to affiliate the entire population because their budget is based on an annual, per family
fee.. The voluntary nature of the affiliation process is an essential feature of the reform that helps democratize
the budget by introducing an element of choice. It discourages adverse selection and provides incentives not
only for universal coverage, but also for good quality and efficiency.
30

Sri Lanka Public Expenditure
on Health
as % of GDP (2013) 1.4
IMR/MMR (2015)
8/30
Life Expectancy
(2013)
74
Community Healthcare :
Community healthcare service is provided through 'Health Units’
comprising up to 80,000 to 100,000 inhabitants. The activities of the health
unit are as following: 1) Conduct a general and special health survey on
all aspects of the health problems in the district, 2) Collect and study vital
statistics of the area, 3) Promote health education, 4) Undertake measures
to control infectious disease, 5) Organize maternal and child health
programs, 6) Conduct school health programs, 7) Develop rural and urban
sanitation projects
Tertiary Care :
Curative care is provided through teaching hospitals,
provincial general hospitals, district general hospitals and
base hospitals (type A and type B). Secondary hospitals
provide four basic specialties (medicine, surgery,
pediatric, obstetrics and gynecology) and manage
patients needing specialist care that are not available in
primary care hospitals, while tertiary hospitals provide
added specialties.
Drug Supply :
State Pharmaceuticals Corporation(SPC) of Sri Lanka procure and supply drugs to the Health Ministry
and to the private sector market through an open competitive tender procedure. SPC distribute
drugs to the general public through island wide network of Rajya Osu Salas,Franchise Osu Salas and
distributors. In Sri Lanka there are about 5000 pharmacies for 21 million people. The total
pharmaceutical market of Sri Lanka today is approximately US$ 365 million of which the private retail
market accounts for approximately 60% of sales while the government hospital purchases account
for approximately 28%, private hospitals account for approximately 10% and dispensing family
physicians account for approximately 2% of the total pharmaceutical business.
Performance-based non-financial
incentives such as career
development, training opportunities
and fellowships were found to be
appropriate for central and
provincial managers, while hospital
managers preferred financial
incentives
Universal Coverage :
Sri Lanka’s model of primary health care, available free through a
government health system with island wide availability, forms a sound
basis for providing universal health coverage. However, with high
burden of non-communicable diseases (NCDs), increasing elderly care
needs and the growing out of pocket expenditure for chronic diseases,
this system is under pressure. Whilst the government’s commitment to
maintaining universal health services of good quality for all continues,
the need for change has been recognized. Primary health care in Sri
Lanka developed as two parallel services: Community health services
and Curative services.
Finance
Financed mainly by the government, with some
private sector participation as well as limited donor
financing. Public sector financing comes from the
General Treasury, generated through taxation. Public
sector services are totally free at the point of delivery
for all citizens through the public health institutions
distributed island-wide, while private sector services
are mainly through ‘out-of-pocket expenditure’
(OOPE), private insurance and non- profit
contribution.
Health Information
Database
The following systems are
present: Patient
Administration System (PAS),
Laboratory Information
Management System
(LIMS), Electronic Medical
Records (EMR), Electronic
Health Records (EHR) and
Management Information
System (MIS)
Accountability
Sri Lanka is an example of how democratic politics can provide a means of government accountability for services to the poor (World Bank 2003). The small size of
electorates encouraged a form of “parish pump politics,” in which national politicians, some elected by as few as 5,000 voters (Wriggins 1960), competed to ensure that the
31

Thailand
Public Expenditure
on Health
as % of GDP (2013) 3.7
IMR/MMR (2015)
11/20
Life Expectancy
(2013)
74
Community Healthcare :
Community hospitals are at the district level and further classified
by size: Large community hospitals have a capacity of 90 to 150
beds, Medium community hospitals have a capacity of 60 beds,
Small community hospitals have a capacity of 10 to 30 beds. While
all three types of hospitals serve the local population, community
hospitals are usually limited to providing primary care, while
referring patients in need of more advanced or specialised care to
general or regional hospitals.
Tertiary Care :
The inpatient care is provided differently in all the three
schemes namely – Civil Servant Medical Benefit Scheme
(CSMBS), Social Security Scheme (SSS) and Universal Coverage
Scheme (UCS). The idea is to provide universal care while
incentivising the fiscal prudence. For example, while care is
provided under UCS, it is capped at global budget. Similarly,
under CSMBS, Diagnosis Related Group (DRG) payment system is
used to disincentivise over-treatment
Drug Supply :
The drugs are procured by the National Health Security
Office (NHSO) and distributed through primary distribution
system ( in which the government drug procurement office
establishes a contract with a single primary distributor, as
well as separate contracts with drug suppliers) attached to
each of the clinics. The drugs can be sourced at subsidised
price on furnishing prescription.
Health Information Database
Ministry of Public health is currently reforming its health information system to
streamline its administrative, financial management and to assess health outcomes
of the intervention in order to improve targeting. The UCS contributed significantly
to the development of Thailand’s health information system through hospital
electronic discharge summaries for DRG reimbursement, accurate beneficiary
datasets and data sharing. The creation of the NHSO’s disease management system
increased better achievement of outcomes
Finance
Mainly funded through taxation and co-contribution of both employer and
employee
Universal Coverage :
99.5% of the population is covered under three of the schemes i.e.,
CHMBS, SSS and UCS
Accountability
Various mechanisms established by the NHSO to
protect beneficiaries: a “1330” hotline, a patient
complaints service, a no-fault compensation fund,
stepwise quality improvement and tougher hospital
accreditation requirements.
The government enforces a three-year compulsory public service for new medical graduates and many financial incentives for rural doctors, including hardship allowances,
no-private practice allowances, overtime payments, and non-official hours special service allowances. These financial incentives have been allowed to increase up to 20
percent after the implementation of the universal coverage scheme. Measures to hire retired physicians is also implemented. For long term measures, the government
approved a project to accept additional 10,678 medical students from 2005-2014 (The Secretariat of the Cabinet 2004). In order to ensure equity of education, longer
rural retention, and local acquaintance, the additional new medical students will be recruited from the rural provinces/districts and trained in provincial hospitals.
32

The best form of providing health protection would be to change the
economic system which produces ill health, and to liquidate ignorance,
poverty and unemployment. The practice of each individual purchasing his
own medical care does not work. It is unjust, inefficient, wasteful and
completely outmoded ... In our highly geared, modern industrial society,
there is no such thing as private health — all health is public. The illness and
maladjustments of one unit of the mass affects all other members. The
protection of people's health should be recognised by the Government as its
primary obligation and duty to its citizens.
- Norman Bethune
Reform Agenda
33
”

National Commission on Macroeconomics and Health, 2005
Health
Financing
•Increase public spending to 3% of GDP
•Increase public investment to primary health care for
providing universal access to a basic package of
services at CHCs and facilities below it, alongside
reorganizing the structure for enhancing
accountability and increased sharing of oversight
functions by the communities and local bodies
Utilization of
IT services
•Introduce and intensively promote use of IT in health
care for patient care in 3 areas : 1) Telemedicine, 2)
computerized data management and record keeping;
3) training through the Edusat facility
Drug
Delivery
•Centralized pooled procurement of drugs reduce
government expenditure by over 30%-50%
• For making drugs available at reasonable prices in the
public health system, autonomous bodies should be
established at the Central and State levels
Standardized
Treatment
Protocols
•Standardization of treatment protocols and unit cost
estimations should be taken up and a schedule of benefits
published. This then could be the basis for public funding
of health in both public and private facilities. This will also
enable people to get an idea of how much a service
ought to cost and protect them from being exploited
Organization
al
restructuring
•Gradually shift towards a mandatory Universal Health
Insurance System for secondary and tertiary care
• Action should be initiated to put in place the appropriate
regulatory and institutional mechanisms, for example, the
necessary health laws to govern health insurance business
and a health regulator to oversee the enforcement of
such regulations
Institutional
infrastructure
•National Drug Authority (NDA) with an autonomous status
to take up the functions of drug pricing, quality, clinical
trials, etc. need to be implemented
• National Institute for Health Information and Disease
Surveillance to be established for a systematic policy
approach to research and evidence
Various committees of experts have been appointed by the government from time to time to render advice about different health
problems. The reports of these committees have formed an important basis of health planning in India. (Annex 10)
34

High Level Expert Group Report on Universal Health Coverage for India, 2010
Financing
•Increase public expenditure to 2.5% and 3% of GDP by
2017 and 2022 respectively
•Ensure availability of free essential medicines
•Do not use insurance companies to purchase health
care services
Service Norms
•focus significantly on primary health care
•Strengthen District Hospitals
•equitable access to functional beds for guaranteeing
secondary and tertiary care
Human
Resources
•Establish a dedicated training system for Community
Health Workers
•increasing HRH density to achieve WHO norms of at
least 23 health workers per 10,000 population (doctors,
nurses, and midwives)
Community
Participation
•Transform existing Village Health Committees into
participatory Health Councils
•Strengthen the role of civil society and non-governmental
organizations
•Institute a formal grievance redressal mechanism at the
block level
Access to
Medicines
•Revise and expand the Essential Drugs List
•Enforce price controls and price regulation especially on
essential drugs
•Empower the Ministry of Health and Family Welfare to
strengthen the drug regulatory system
Institutional
Reforms
•Develop a national health information technology
network to ensure inter-operability between all health
care stakeholders
•Ensure accountability to patients and communities
•Invest in health sciences research and innovation to
inform policy, programmes and to develop feasible
solutions
35

Limitations of existing approaches
1. Public sector provider
model:
- Lacks incentive to
provide quality healthcare
- Huge Corruption
-Lost public confidence
2. Fee for service model:
- Over treatment
- Cost escalation
3. Capitation payment
model:
- Under treatment
4. Traditional Insurance
model:
- Causes avoidable
suffering and escalates
costs
- Adverse selection of
beneficiaries
- Moral hazard
36

Spending does not improve health automatically!
0
2
4
6
8
10
12
14
16
18
United States Japan Australia Italy Spain Iran Thailand Singapore India Bangladesh
COMPARISON OF HEALTH EXPENDITURE WITH DISABILITY -ADJUSTED LIFE YEAR (DALY) RANKING
Total health expenditure as % of GDP
51*1*
36*
47*
4*
41*
3*5*
2*
24*
* The numbers indicate DALY rankings (Annex 9)
37

Health Outcomes
Public Spending on
Health
High Quality
Institutions
Cost-Effective
Interventions
Source: Spence and Lewis 2009. Health and Growth: The World
Bank and the Commission on Growth and Development.
Appropriate
Delivery Models
Spending does not improve health automatically!
What we need…
38

Health Domains Public Funded Private Funded
Cost-effective
option
Public and Preventive
Health
Strong Positive
Externalities
No Markets Public
Primary Care
Positive Externalities
No choice - No
Accountability
Disincentive for
preventive part
Public- Private
Partnership
Secondary Care Inefficiency Overtreatment
Choice and
Competition
Tertiary Care Centres of Excellence Overtreatment Public and NGOs
Cost-effectiveness in Healthcare
39

40
Framework for a Universal Healthcare Model

Primary and Preventive Healthcare – Main Features
At the heart of the Primary and
Preventive Care lies the Family
Physician (FP)
FP is a private provider who is
contracted by a Regional Health
Trust (RHT) from a pool of available
doctors
S/he is a qualified doctor who is
certified in family healthcare. (Eg. 3-
month certification courses can be
tailored to suit this need)
3 to 4 additional staff including
assistant, lab technician, data
analyst, etc. will assist the FP
Basic diagnostic facilities such as
blood and urine tests will be
provided at the clinic
The FP would generally reside in the
community/area s/he practices. In
rural areas, the FPs will reside in
small towns where nearby villages
are covered. This will ensure
sufficient rural penetration where
the FP need not necessarily have to
be in the village s/he serves
Each FP is expected to register
about 5000 people with him
Doctor – patient
relationship
Registration and
electronic records
Primary and
preventive healthcare
Referrals and Linkages
Choice and
competition
The Family
Physician
41

Family Physician – Main Features
Doctor-Patient Relationship
The core aspect of the model is the direct
interaction of the patient with the Family
Physician, This will build a bond of trust
and act as a psychological booster. Thus,
such consultations can ensure holistic
healthcare rather than merely treating
the patient.
Choice and Competition
It is up to the people to choose their
Family Physician from a pool of
available doctors. This element of
choice would enable competition
where FPs in a geographic area
would vie to provide the best services
in order to attract registrations.
Registration and electronic records
AADHAR will be the mandatory basis for
registration and availing of services.
Subsequently, electronic health records
of the patients will be available. These
records will be monitored by the
Central Health Monitoring Agency
(CHMA). They can be digitally
transferred to respective FP if the
patient changes his provider.
Referrals and Linkages
A key aspect of FPs is to make referrals to
secondary care. These are mandatory for
elective non-emergency procedures. This will cut
down overdiagnosis and overtreatment.
Also, FPs will have linkages with Primary Health
Center (PHC), Regional Health Trust (RHT) and
secondary referral hospitals in order to improve
accessibility to needed services. Feedback
mechanisms from FPs to RHT and secondary
referral hospitals and vice versa will ensure better
healthcare practices.
42

Primary Health Center (PHC) – Basic Functions
The linkages between the FP and the PHC is crucial for smooth access to health services such as basic diagnostics, etc.
Free generic drug
supply
Diagnostics such
as X-ray, Scanning
etc.
Local nutrition
and sanitation
programmes
Mosquito control
and disease
control
programmes
And other related
tasks
Field visits and
epidemiological
surveys
There are 25,308 PHCs and 1,53,655 sub-centers in India as of 2015.*
They can be integrated into the FP model by concentrating on those services which complement the Family Physician’s duties.
43

Free generic drug
supply
Diagnostics such as
X-ray, etc.
Field visits and
epidemiological
surveys
Local nutrition and
sanitation
programmes
Mosquito control and
disease control
programmes, etc.
Primary Health Center
Primary and
preventive
healthcare
Basic diagnostics like
Urine and Blood test;
Referrals
Electronic records
Registration
Free generic drug
supply
Family Physician
Primary and Preventive Health Care
44

Primary and Preventive Healthcare Expenditure Estimates (by 2022)
Per capita expenditure proposed Rs. 700
Population projected 1.4 billion* (140 Crores)
Projected out patient public health expenditure 700*140 crores
Costs including Out patient care, Immunization, Family
planning, Simple diagnostics, Generic drugs, Maternal and
child care
Rs. 1,00,000 crores (Approx.)
Cost of maintaining existing infrastructure and primary health
centers(auxiliary staff , administration etc.)
Rs. 25000 crores (Approx.)
Expected Cost for outreach, cold chains, diagnostic centers,
CHMA, drug supply, electronic patient record, etc.
Rs. 25000 crores (Approx.)
Total projected public health expenditure on primary and
preventive healthcare
Rs. 1,50,000 Crores
* Provisional by 2022, World Population Prospects, The 2015 Revision by
Department of Economic and Social Affairs, UN.
45

Central Health Monitoring Agency (CHMA)
This government agency is envisioned as
central level IT infrastructure-based
monitoring and controlling agency.
Patient records are linked to their
AADHAR.
All the FP clinics, PHCs, CHCs, drug
dispensaries of approved private
hospitals, diagnostic centers and Drug
Supply Agency are digitally linked to this
central database.
46

Secondary Healthcare
A number of carefully chosen
small nursing homes (30 bed)
subject to certain minimum
standards where costs, quality of
service are predefined will be
contracted and paid by the RHT.
CHCs will act as
polyclinics and
cater to advance
diagnostics like
radiology, CT Scan
etc. Pooling of
diagnostics can be
looked into.
Call centers can be
constituted for
information
dissemination and
appointment/queueing
mechanisms.
Free drug dispensary (both at
CHCs and pvt. nursing homes) to
provide free generic medicine
through electronic prescription
linked to DSA and CHMA.
Linkages including feedback
mechanisms among
contracted private nursing
homes, CHCs and tertiary
referrals hospitals. Feedback to
FPs/PHCs regarding referrals
from primary care level.
There are 5396 CHCs in India.*
Over the next 5-10 years they
can be increased to 10,000.
This would ensure at least one
CHC for every 125000
population
Referrals from FP/PHC is
mandatory for elective
non-emergency
procedures in both
contracted private
nursing homes and
CHCs.
Predefined conditions for
allowing pvt. nursing homes
in emergency care and life
saving techniques including
basic trauma care. Patient
mobility from home to
CHC/pvt. nursing homes.
The basic aim is to ensure healthy competition between Community Health Centers (CHCs)/public
providers and private nursing homes and adequate choice to the patient.
CHC’s and small
private nursing homes
will compete except
in the case of pooled
facilities.
47

Polyclinic
Free generic drug
supply
Advanced
Diagnostics such
as MRI, CT scan,
etc.
Electronic records
Referrals and
Linkages
Trauma/
Emergency care
Free generic drug
supply
Specialists
Community Health
Centers (CHCs)
Private nursing homes
contracted through RHTs.
Secondary Healthcare
48

Secondary Healthcare Expenditure Estimates (by 2022)
Population projected 1.4 billion* (140 Crores)
Assuming number of beds (public hospitals, accredited small nursing
homes, etc.)
10,00,000
Assuming, per bed cost per annum (including interventions,
diagnostics and drugs)
Rs.10,00,000
Total projected public health expenditure on secondary care Rs.10,00,000*10,00,000
= Rs.1,00,000 crores
Expenditure on support agencies such as RHT, Ombudsman, etc.
Rs. 50,000 crores
Total projected public health expenditure on secondary healthcare
(including support agencies)
Rs. 1,00,000 crores
+50,000 crores =
Rs. 1,50,000 crores
* Provisional by 2022, World Population Prospects, The 2015 Revision by
Department of Economic and Social Affairs, UN.
49

Regional Health Trust (RHT)
Money flows to RHT from the Govt.
on capitation basis.
RHT contracts/pays the Family
Physician at the Primary Level and
Pvt. Nursing homes at the
secondary level.
RHT will spend more on primary
and preventive care to curtail
tertiary care costs.
Model 1
Model 2
Private agencies will bid to
provide comprehensive
healthcare for a geographical
region as an RHT.
Alternatively, instead of private
agents, a body of govt. officials,
representatives from local
governments, medical
profession, family physicians,
pvt. nursing homes at the
secondary level can form an
RHT.
How is an RHT constituted?
1 RHT would cover a population of
roughly 1,00,000
The area covered by RHT and
CHC will be coterminous
50

51
Tertiary
Care
Private run public funded
Referrals & Linkages
Independent consultants
Private services in addition to free public
care
Private Financial Initiative (PFI) will design,
build, finance, and operate the hospital
facilities. Government pays an annual
fee to cover both the capital cost,
including the cost of borrowing, and
maintenance of the hospital and any
nonclinical services provided over the 30-
35 year life of the contract on a "no
service, no fee" performance basis
On a rotation basis, consultants
take up the leadership role. Such a
system of independent work,
leadership opportunities and
incentivised private work along with
a reasonable remuneration (Rs. 2-3
lakhs) to begin with will drive many
private specialists and NRIs with
experience to join these institutions
To drive the standards up not just for revenues. Large private
care blocks will be built in the hospital.
Doctors earn extra money through these services. This will
provides a strong incentive for the bright and best to join
and sustain in these hospitals.
Referrals from secondary care on
elective procedures. Linkages with
private nursing homes (contracted at
secondary care level), CHCs as well as
RHTs including feedback mechanisms
with all the mentioned entities.
Upgradation
All district hospitals(approx. 500+)
will be upgraded and will
function as tertiary care centers
Education and
Research
Public sector teaching hospitals
will also serve as centers of
excellence for education,
training and research

Tertiary Healthcare Expenditure Estimates (by 2022)
Building or upgrading of 500 SIMS tertiary hospitals (Including Govt.
Teaching hospitals)(1 per 2.8 million population)
PFI lease per hospital per year Rs. 50 crore
Running cost per hospital per
year
Rs.150 crore
Total cost per hospital per
year
Rs. 200 crore
Total Tertiary Care 500*200 crores
Rs. 1,00,000 crore
52

Key Institutions – DHB/SHBs
Every state constitutes a State Health Board which will oversee
the healthcare of the state through District Health Boards
(DHB)s.
DHB will have control of all
the data in the district to aid
all its operations.
It is responsible to reach the
targets of the national
programmes with different
geographically appropriate
goal posts.
It will have autonomy in
deciding the payments. It
can also provide for financial
incentives to attract
professionals to remote areas
Expected Funding - central
and state governments.
District Health Boards(DHB) & State Health
Board(SHB)
DHB and SHB are fully in-charge of Tertiary Healthcare and
Teaching Hospitals respectively
53

Support Institutions – Trauma Trust
A single authority to
streamline measures to
prevent road accidents,
‘golden hour’ care, further
treatment and integrating
the existing private third
party insurance for the road
vehicles.
Merging Road Safety
Authority of India with
Trauma Trust
Implementing preventive
measures working closely
with transport authorities
RTA registry: to monitor the
patterns of the accidents
Major trauma centres along
the national highways
Trauma ambulance network
for highways
Trauma networks – Linking
Govt. and private trauma
care and ambulance
services
Massive education
campaigns- educating the
road users should be taken
up in a big way.
Contracting treatment by
the private hospitals if there
is no Govt. hospital within 30
km.
Extensive training of
ambulance personnel, strict
Advanced trauma life
support (ATLS) protocol
based management
Workforce management,
liaising with paramedical
education standard institute
Constant monitoring and
feedback to study the
effect of the preventive
measures
54

Key Institutions – DSA/ Regulatory Bodies
Drug Supply Agency(DSA) Regulatory Bodies
Direct free distribution of the necessary
‘low cost but high quality’ generic drugs
Digital logging of the prescriptions (linked
to Aadhaar no.) in the primary, secondary
and tertiary centers linked to CHMA
Drug dispensaries on replenishment model
will curtail over-prescription
Digital Monitoring to check over-
prescription, unusual patterns, excessive
antibiotic usage, etc
Expected funding through central
government
There should be independent bodies to
check quality of services, standard of
protocol, costs, diagnostics, etc
In addition, an ombudsman at the district
level :
With real authority to prosecute- blacklist,
cancel registration of FPs, etc.
Restructure Medical Council of India to suit
the present needs of the system
Specialization
There is a need to substantially
increase the number of specialists,
nurses and technicians.
Legal Framework
States should come up with
respective legal framework.
Sharing mechanisms for finances
between the center and the
states should be worked out. It
should be on the basis of 50 : 50.
55

Overview
Primary and Preventive Healthcare Model
Secondary Healthcare Model
Teritary Healthcare Model
Family Physician Primary Health Center
Private Nursing
Homes/Hospitals
Community Health Center
Government hospitals (private
build / maintenance /operation)
Specialist/Teaching hospitals
CHMA
RHT
DHB
SHB
DSA
Ombudsman
Trauma Trust
56

Integrated Public Health
Mandatory
health
education air-
time in all the
Govt. and
private TV
channels
High quality
epidemic team
Massive public
health
education
programmes
Health helpline
Integrating
sanitation and
clean water
provision to the
healthcare
system in
accountability
pathways
Extended
immunisation
schedule
including MMR
and Hepatitis B
Digitalised primary care
network of Family Physician
clinics linked to CHMA as
described above solves the
problem of deficiency of
population health data
Integrating the proposed CHMA and National Institute
of Clinical Excellence with the existing Public Health
Foundation of India (PHFI) and
Indian Institutes of Public Health (IIPH) will pave the
way to develop real-time evidence and research
based planning model of excellence.
Public Health initiatives
• ‘No injection needed’ campaign
• Sanitation campaign
• Hand hygiene campaign
• Early detection campaigns for of TB, cancer,
diabetes, hypertension
• Maternity care campaign, Vaccination campaign
57

Public Private Partnerships as described so far
Careful regulation to avoid hindering the growth
Encouraging the private centres of excellence
Encouraging proactive disclosure of information on public domains
Integrating in health education campaigns
Grievance mechanisms for the patients (technology based)
Private Health Care
58

Universal Healthcare Expenditure Estimates (by 2022)
Primary and Preventive Rs. 1.5 lakh crore
Secondary Rs. 1.5 lakh crore
Tertiary Rs. 1 lakh crore
Total Rs. 4 lakh crore
Projected nominal GDP of India by 2022 Rs. 240 lakh crores
Universal Health Expenditure as % of GDP
by 2022
1.67% (Currently 1.3%)
59

Country
Population
(in millions)
Health
Workforce
(in millions)
% of Health
Workforce in
total population
USA 318.9 12.2 3.8
UK 64.1 1.6 (NHS) 2.4
India 1250 3.6(2013)* 0.28
• Compared to countries such as USA
and UK, India has a very low health
workforce to population ratio
• By correlation, the expected number
of people employed in healthcare in
India should be around 10 times what
it is now i.e. almost 40 million
• Even a conservative number of 20
million(half of the ideal scenario)
shows a wide gap given the existing
workforce of 3.6 millions i.e. a deficit of
82%
Universal Healthcare has huge potential to
generate employment in the health industry, at
different levels(support staff, pharmacists,
administration staff, regulation staff, IT staff etc.) to
the tune of atleast 15 million jobs over a decade.
Health Sector Can Create Jobs !
*Human Resource and Skill Requirements in the Healthcare Sector- NSDC,KPMG
Workforce demand projections of India across various roles in healthcare (Annex 11)
60

Primary and Preventive Healthcare
1. Training for the Family Physician (FP)- Period, curriculum
Views :
2. Certification of the FPs- Certifying authority?
Views :
3. The registration of people with the FP- Minimum Duration
Views :
4. What should be the FP to population ratio?
Views :
5. For registration, who/what will be considered as a unit- Individual or a family?
Views :
6. Suggest supporting staff for an FP such as ANM, lab technicians, data management staff etc.
Views :
7. Supply of generic drugs by an FP-
a. Feasibility of prescribing only generic medicines.
b. Procurement and supply.
Views :
8. What are the lab facilities that should be made available at a PHC?
Views :
ISSUES TO BE RESOLVED
61

9. Generic drug pooling at the PHC level- procurement and supply to the FPs
Views :
10. How will the existing PHC staff be involved in the proposed model? – Surveillance, traditional services etc.
Views :
11. Linkages-
• FP to PHC
• FP to RHT
• FP to Referral hospitals at the secondary level and vice versa.
Views :
12. Integration of informal medical practitioners (AYUSH,RMP etc.)
a. Is it required?
b. If yes, will it be feasible to integrate them into the proposed model and how?
Views :
62

13. What should be the capitation fee which would fulfil the requirements of a Family Physician? (our proposal is Rs. 700/patient)
Views :
14. Lab technicians – mechanism to monitor and quality control?
Views :
15. Transport linkages from village to FP-
a. Should transport facilities be provided to the villagers to travel to the respective FP residing in towns?
b. Mechanism by which transport facilities can be provided?
Views :
16. How to monitor the PHCs in the changed context?
Views :
63

17. Family physician-
a. Norms for accessing- How many number of times can the patients be allowed to visit the doctor ?(need based, routine, pregnancy check-ups)
Views :
b. Standard Protocols- Family practice – National template and local protocols
Views :
c. Drug procurement- contractual agreements
Views :
d. Feedback Mechanisms – How can each patient give feedback about the doctors?
Views :
e. The respective FP’s feedback to public health system on sanitation, water supply, nutrition etc.
Views :
f. How should we provide Continuous Medical Education(CME) to an FP?
Views :
18. What should be the composition of the Regional Health Trust (RHT)?
Views :
64

Secondary Care
1. Standards for choosing a Private Nursing Home as a referral hospital?
Views :
2. What should the CHC, population ratio be ideally? (1:1,00,000?) (currently, it is 1:2,30,000)
Views :
3. How much geographic area should a CHC cover?
Views :
4. Can the patient choose the secondary care provider or is it up to the FP to refer?
Views :
5. What should be the minimum requirements of secondary level hospital? – (number of doctors, beds, diagnostics, facilities etc.).
Views :
6. a. How can we attract specialists (ophthalmology, ENT, Dental, orthopaedics, etc.) at the secondary level?
b. Should there be separate facilities for each speciality at the secondary level?
Views :
7. Standards and norms for diagnostic facilities at CHCs
Views :
8. Scope of care in secondary care facilities
Views:
65

Secondary Care
9. Information and Billing Mechanisms- (fee per service model)
a. Standard Services provided at the CHCs and Private Nursing Homes?
b. Standard Costs for each service
Views :
10. Emergency Care –How can we ensure 24*7 emergency services?
Views :
11. Transport – from villages to the secondary healthcare providers – is it necessary?
Views :
12. Generic Drugs- Surgical consumables and Medicines
a. Procurement and Distribution of Generic Drugs
b. Would generic drugs suffice at the secondary level?
c. If no, mechanism for procurement, costing, supply etc. of branded drugs
Views :
13. Linkages-
• CHC- FP
• CHC- RHT
• CHC- Private Service providers
• CHC- Tertiary care (referrals) and vice versa
Views :
14. Feedback Mechanism –
• Patients feedback on CHCs and Pvt. providers
• FP’s feedback on CHCs and Pvt. providers
• CHC feedback on FPs
Views :
66

Secondary Care
15. Fee for service- Mechanisms to monitor care and billing by the CHCs and pvt. providers by RHT/DHB
Views :
16. What kind of pooled diagnostic facilities should be made to host sophisticated diagnostic tools (MRI, CT Scan etc.)
Views :
17. Do we need a separate pooled pathology lab at the secondary level?
Views :
18. Call Centre –
a. Should there be a call centre to address patients’ need for information (costs, ratings, availability, etc. ) and manage appointments – pros and cons
b. Should we have it at the RHT level or District level?
Views :
19. Elective services - Appointment procedure and Queuing process
Views :
20. Record keeping and Data Integration at the secondary level
Views :
21. Review of the secondary care services – costs, people to bed ratio etc.
Views :
22. Training of new specialists – through Diplomate of National Board (DNB)- total number of doctors needed, how can we ensure quality of education at
the secondary level?
Views :
23. Road trauma issues – ensuring availability of ambulance services and integration with secondary care hospitals
Views :
24. What should be the composition of District Health Board (DHB)?
Views :
67

Tertiary Care
1. How should the queuing be for elective procedure at the tertiary level?
Views :
2. What should be the minimum requirements for a district level tertiary care centres? –
a. No. of beds
b. Basic amenities
c. Diagnostic equipment, etc.
Views :
3. How can we retain doctors at the tertiary level? What kind of incentives need to be given to attract enough tertiary care specialists?
Views :
4. If there is a shortage of specialists at the tertiary level, should the private specialists be hired on a contractual basis?
Views :
5. How can the tertiary level be linked with the secondary level?
Views :
6. What should the feedback mechanism at the tertiary level so that they can advise and train the personnel of secondary level?
Views :
7. How should the drug supply be managed at the tertiary level? Should it be done at central level or local level?
Views :
68

Tertiary Care
8. What models should be considered to build and maintain the private infrastructure at the tertiary level?(Build operate transfer etc.)
Views :
9. Should there be any tax incentives/exemptions for the health equipment at tertiary level?
Views :
10. How can the tertiary care hospitals be linked with the teaching hospitals?
Views :
11. Should there be specialized referral centres for complex cases?
Views :
12. Feedback mechanisms and linkages of-
a. District Health Board (DHB)
b. State Health Board (SHB)
c. Secondary Care Centres
d. Teaching Hospitals
Views :
13. Is insurance model a better option at the tertiary level?
Views :
69

Supporting Institutions
1. How can we manage/secure data at different levels (Primary, secondary & tertiary)?
Views :
2. How should a district ombudsman mechanism be designed? Does it require legal backing?
Views :
3. Ensuring funds
a. How can we ensure guaranteed funding to RHTs, DHBs?
b. If it is done by a law, should each state enact separate laws (or) should there be a national law?
Views :
4. What should be the composition of the following institutions
• State Health Boards (SHB),
• Drug Supply Agency (DSA)
Views :
Financing
6. The ratio of state and union financing for universal healthcare.
Views :
7. What are the key reforms needed to suit universal healthcare model?
Views:
70

72
Margaret Mead
Never doubt that a small group
of thoughtful, committed
citizens can change the world;
indeed, it's the only thing that
ever has.

Sr. No Country
GDP (in
billion
dollars)
Per Capita
Income
(2014)
HDI Rank
(UNDP)
Out-of-Pocket
expenditure
( % of private
expenditure
out of total
expenditure)
Life
expectancy
(years)
Private
Health
Expenditure
(% of GDP)
(2013)
Public
Expenditure
(% of Total
Health
Expenditure)
(2013)
Age Standardized
Disability Adjusted
Life Years (DALY)1
rates
(per 1,00,000
population)
(2012)
DALY
Rank
1 USA 14796.6 54629.5 5 22.3 78.84 9 47.1 22775 24
2 China 5274.1 7590 91 76.7 75.35 2.5 55.8 24811 26
3 Japan 4779.5 36194.4 17 80.2 83.33 1.8 82.1 15700 2
4 Germany 3212.7 47821.9 6 55.6 81.04 2.6 76.8 19224 12
5 U.K 2642.8 46332 14 56.4 80.96 1.5 83.5 20376 20
6 France 2361.4 42732 20 32.9 81.97 2.6 77.5 19104 11
7 Italy 1747.1 34908 26 82 82.29 2 78 16957 3
8 India 1600.3 1581 135 85.9 66.46 2.7 32.2 47950 51
9 Canada 1361 50235 8 50.1 81.4 3.3 69.2 18838 10
10 South Korea 1238.7 27970 15 78.6 81.46 3.3 53.4 17921 7
11 Brazil 1206.1 11384 79 57.8 73.89 5 48.2 31632 42
12 Spain 1188.8 29767 27 77.1 82.43 2.6 70.4 16984 4
13 Mexico 1067.9 10325 71 91.5 77.35 3 51.7 26763 29
14 Russia 999.8 12735 57 92.4 71.07 3.4 48.1 39906 48
15 Australia 888.6 61925 2 57.1 82.2 3.2 66.6 17696 5
16 Netherlands 727.1 52172 4 41.7 81.1 1.7 79.8 18770 9
17 Turkey 672.8 10515 69 66.3 75.18 1.3 77.4 29027 37
18 Saudi Arabia 523.4 24161 34 55.3 75.7 1.1 64.2 27174 32
19 Indonesia 471.7 3491 108 75.1 70.82 1.9 39 36015 46
20 Sweden 446.3 58938 12 88.1 81.7 1.8 81.5 18308 8
21 Poland 429.5 14342 35 75 76.85 2.2 69.6 25415 27
22 Belgium 425 47352 21 82.3 80.39 2.7 75.8 19878 19
23 Austria 350.6 51190 21 65.2 80.89 2.7 75.7 19763 16
24 Norway 345.4 97307 1 95.9 81.45 1.4 85.5 19615 14
25 Argentina 332.6 12509 49 65.3 76.19 2.4 67.7 26808 30
26 South Africa 328.7 6482 118 13.8 56.74 4.6 48.4 67514 53
27 Denmark 268.1 60707 10 87.4 80.3 1.6 85.4 20451 21
28 Hong Kong 247.8 40169 15 - 83.83 - - - N/A
29 U.A.E 243.4 43962 40 63.2 77.13 1 70.3 25546 28
30 Thailand 232 5977 89 56.7 74.37 0.9 80.1 28993 36
Source: World Bank, UNICEF & UNDP
Health Data of top 50 countries (in terms of GDP)
31 Iran 231.4 5442 75 88 74.07 4 40.8 30911 41
32 Ireland 227.7 54374 11 52.1 81.04 2.9 67.7 19319 13
33 Colombia 222.6 7903 98 58.1 73.98 1.6 76 27188 33
34 Malaysia 220.5 11307 62 79.9 75.02 1.8 54.8 29765 40
35 Finland 212.2 49823 24 75 80.83 2.3 75.3 19843 18
36 Singapore 208.3 56284 9 94.3 82.35 2.7 39.8 14354 1
37 Israel 201.6 37208 19 64.5 82.06 3 59.1 17719 6
38 Greece 201.4 21498 29 86.6 80.63 3 69.5 19627 15
39 Nigeria 194.9 3203 152 95.8 52.5 2.8 27.6 84764 54
40 Portugal 190.3 22132 41 75.4 80.37 3.4 64.7 19815 17
41 Venezuela 186.9 12,771(2012) 67 90.2 74.64 2.6 27.1 29410 39
42 Chile 175 14528 41 60.3 79.84 4.1 47.4 21333 22
43 Philippines 165.1 2872 117 82.9 68.71 3 31.6 41446 49
44 Czech Rep. 157.1 19529 28 94.1 78.28 1.2 83.3 22380 23
45 Pakistan 151.6 1316 146 86.8 66.59 1.7 36.8 50534 52
46 Qatar 137.9 96732 31 52.2 78.61 0.4 83.8 22923 25
47 Algeria 132.4 5484 93 97.2 71.01 1.7 74.2 34790 43
48 Egypt 131.4 3198 110 97.7 71.13 3 40.7 35784 45
49 Peru 127.7 6541 82 84.6 74.81 2.2 58.7 26911 31
50 Romania 123.4 9996 54 97 74.46 1.1 79.7 28496 34
51 Bangladesh 119 1086 142 93 70.69 2.4 35.3 38814 47
52 Hungary 117.2 14028 43 75.5 75.27 2.9 63.6 28707 35
53 Vietnam 97.8 2052 121 85 75.76 3.5 41.9 29226 38
54 Kazakhstan 96.4 12601 70 98.9 70.45 2 53.1 42804 50
55 Ukraine 89 3082 83 94 71.16 3.5 54.5 35121 44
1. DALY(Disability Adjusted Life Years) = YLD(Years lived with Disability) + YLL(Years of life lost).
YLD and YLL are calculated as a function of Cause, Age,Sex and Time. Higher the DALY poorer the health conditions in a country
Sr. No Country
GDP (in
billion
dollars)
Per Capita
Income
(2014)
HDI Rank
(UNDP)
Out-of-Pocket
expenditure
( % of private
expenditure
out of total
expenditure)
Life
expectancy
(years)
Private
Health
Expenditure
(% of GDP)
(2013)
Public
Expenditure
(% of Total
Health
Expenditure)
(2013)
Age Standardized
Disability Adjusted
Life Years (DALY)1
rates
(per 1,00,000
population)
(2012)
DALY
Rank
Source: World Bank, UNICEF & UNDP
Health Data of top 50 countries (in terms of GDP)
Annex 9
82

Various Committee Recommendations
1. BHORE COMMITTEE, 1946.
This committee, known as the Health Survey & Development Committee, was appointed in 1943 with Sir
Joseph Bhore as its Chairman. It laid emphasis on integration of curative and preventive medicine at all
levels. It made comprehensive recommendations for re-modelling of health services in India.
2. MUDALIAR COMMITTEE, 1962.
This committee known as the “Health Survey and Planning Committee”, headed by Dr. A.L. Mudaliar, was
appointed to assess the performance in health sector since the submission of Bhore Committee report. This
committee found the conditions in PHCs to be unsatisfactory and suggested that the PHC, already
established should be strengthened before new ones are opened.
3. CHADHA COMMITTEE, 1963.
This committee was appointed under chairmanship of Dr. M.S. Chadha, the then Director General of Health
Services, to advise about the necessary arrangements for the maintenance phase of National Malaria
Eradication Programme. The committee suggested that the vigilance activity in the NMEP should be
carried out by basic health workers (one per 10,000 population), who would function as multipurpose
workers and would perform, in addition to malaria work, the duties of family planning and vital statistics
data collection under supervision of family planning health assistants.
Annex 10
83
Source : National Institute of Health and Family Welfare(last accessed on 5th April 2015)

4. MUKHERJEE COMMITTEE, 1965.
The recommendations of the Chadha Committee, when implemented, were found to be impracticable
because the basic health workers, with their multiple functions could do justice neither to malaria work
nor to family planning work. The Mukherjee committee headed by the then Secretary of Health Shri
Mukherjee, was appointed to review the performance in the area of family planning. The committee
recommended separate staff for the family planning programme. The family planning assistants were to
undertake family planning duties only. The basic health workers were to be utilised for purposes other
than family planning. The committee also recommended to delink the malaria activities from family
planning so that the latter would received undivided attention of its staff.
5. MUKHERJEE COMMITTEE. 1966.
Multiple activities of the mass programmes like family planning, small pox, leprosy, trachoma, NMEP
(maintenance phase), etc. were making it difficult for the states to undertake these effectively because
of shortage of funds. A committee of state health secretaries, headed by the Union Health Secretary, Shri
Mukherjee, was set up to look into this problem. The committee worked out the details of the Basic
Health Service which should be provided at the Block level, and some consequential strengthening
required at higher levels of administration.
6. JUNGALWALLA COMMITTEE, 1967.
This committee, known as the “Committee on Integration of Health Services” was set up in 1964 under
the chairmanship of Dr. N Jungalwalla, the then Director of National Institute of Health Administration
and Education (currently NIHFW). It was asked to look into various problems related to integration of
health services, abolition of private practice by doctors in government services, and the service
conditions of Doctors.
84

7. KARTAR SINGH COMMITTEE. 1973.
This committee, headed by the Additional Secretary of Health and titled the "Committee on multipurpose workers under
Health and Family Planning" was constituted to form a framework for integration of health and medical services at
peripheral and supervisory levels.
8. SHRIVASTAV COMMITTEE. 1975.
This committee was set up in 1974 as "Group on Medical Education and Support Manpower" to determine steps needed to
(i) reorient medical education in accordance with national needs & priorities and (ii) develop a curriculum for health
assistants who were to function as a link between medical officers and MPWs.
9. BAJAJ COMMITTEE, 1986.
An "Expert Committee for Health Manpower Planning, Production and Management" was constituted in 1985 under Dr. J.S.
Bajaj, the then professor at AIIMS.
OTHER COMMITTEES AND COMMISSION REPORTS
• National Commission on Macroeconomics and Health
• Indian health information network developmentreport on use of ict in health care and knowledge management
recommendations for the national knowledge commission
• Col. S. S. SOKHEY ON NATIONAL HEALTH
• Udupa K.N. Committee on Ayurveda Research Evaluation, 1958
85

State/UT wise Health Human Resource in Rural Areas(Govt.) in India
as on 31.03.2014
National Health Profile 2015
87
Annex 12

Loksatta's Roadmap to Universal Healthcare

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