INCLUSION: What is the state of health sector in India?
Chandra Kishore Mishra: Ground level transformation has happened post-2008. Notable being National Rural Health Mission (NRHM). It was based on three premises— one, the investment levels in health are very low and private sector is not there particularly in primary healthcare sector; second, we are running far too many vertical programmes separately to have any combined impact; and, third, we need specifically to engage with states.
States were given flexiblility to choose programmes, which suited their needs. This means that inequities within the states were recognised. Since health is a State subject, Centre could only prod and provide for finances. We also increased our investment. Earlier the State to Centre ratio was something like 25:75; it is now at about 35:65.
We also built a plan based on specific needs of block level or district level hospitals etc. Our primary concerns were Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR), which have shown significant improvements. Our death rate has also declined compared to the world averages.
INCLUSION: If we look at the data in terms of percentages, do we look better?
CKM: We are still worse than the world average. That is because we have historical baggage. So, if you look at the data of 2000 and see where the world was and where we were and compare it with today’s situation, you will see tremendous improvement but in terms of numbers we would still be higher than the rest of the world.
We introduced new programme for non-communicable diseases. Finally, in 2013 we realised that urban slums were getting neglected. Thanks to NRHM, the health delivery systems are getting far better organised in urban areas. Since, the modernisation started only recently, the results would be visible by next year.
We are 3rd country in the world, which is moving towards adolescent health. We have 253 million adolescents and unless preventive promotive health is carried out, we might have a sick population, which will be more of a liability than asset. We call it RMNCH+ A (Reproductive Maternal Neo Natal Child Health+ Adolescent). This is doing well.
Even though there is huge shortage of Primary Health Centres (PHCs), the access to healthcare has improved. We chose 184 districts across the country, which had poor access. We advised states to pump in 30 per cent additional resources and measure the access. This has worked.
India has about 58 per cent of out-of-pocket expenditure in health, which is very high and we need to slowly bring it down. So, three new initiatives we have taken are – free drugs, free diagnostic services and free dialysis services. Around 250 districts have already taken off.
OPD services have increased by some 100 times. IPD has increased. Institutional deliveries have gone up from 30 per cent to 85 per cent, which is the biggest achievement that the country has made. Once a woman comes to the hospital, the child and the mother both can be safe. As they get registered in our system – we are bale track about 8 crore women through our Mother and Child Tracking System (MCTS).
INCLUSION: How about insurance?
CKM: Now incidentally most of the states, apart from Rashtriya Swasthya Bima Yojana (RSBY), also have Mukhyamantri Yojna etc with additional cover of `200,00 or so.
Insurance scheme is good for gap filling. May not be the best thing for preventive promotive health because it only takes care of hospitalisation and I feel that if government has to invest money it should be in preventive health. We are not supposed to take care of sick people. That is what I debate—whether you want good healthcare or hospitalcare. Good news is that states have become proactive in investing in healthcare wherein, for instance, in Tamil Nadu there is a move to convert six of the district hospitals into a cathlab facility.
The Government of India is funding all State Medical Colleges to create super specialities. But the biggest problem which we have not been able to solve is the human resource. We produce about 57,000 MBBS students every year. The tragedy, however, is that we only have 25,000 PG seats. As it is, the students are less, only half of them acquire specialisation, so you will always have shortage of specialists in the country. And add to that the specialists coming out of colleges are not willing to work in remote areas. This is an issue that we need to handle.
INCLUSION: Can technology help?
CKM: One of it is Health Management Information System (HMIS). Today in Delhi, I get a monthly report from every facility in the country. Every public health related facility is reports on their HMIS and the central repository pulls data from there. All states are using that. In fact, we insist that all your reviews should be based on that. But this is only applicable up to district level hospitals. Medical colleges are not part of it yet.
INCLUSION: Is there any proposal to use the Digital Locker, which is being given to each citizen?
CKM: We are looking at Electronic Health Records (EHR), which will ultimately result in Digital Lockers, where we can scan and store all medical reports of all patients. We are also working on the patient privacy issues.
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