Abstract
Background:
A healthy nation is a wealthy nation but unfortunately we are standing on a weak ground in terms of our healthcare delivery system. Published in the medical journal, ‘The Lancet’ in the Global Burden of Disease(GBD) study, India is ranked at 154th among 195 countries on the healthcare index.The HAQ index is determined by death rates for 32 diseases that can be avoided or effectively treated with proper medical care.According to WHO statistics, in India, the proportion of lower income classes getting free health care in comparison to the proportion of higher income class with access to free healthcare is 17.33 and 22 respectively.Low insurance coverage and poor public health system are two prime reasons why even poor prefer a private hospital rather than a public hospital for treatment.
Objective:
To Assess the awareness and knowledge of the Indian community regarding health care policies and delivery
Methods:
A cross-sectional observational study was conducted.People were asked to fill a web-based(google forms). Study was conducted in 2 stages, Stage 1 involved collection of data from people of different age groups, socio-economic status and education level.Stage 2 included Focused Group Discussion with people of urban and rural settings to know there knowledge regarding health care policies and delivery system.
Result:
Conclusion:
TABLE OF CONTENT
Introduction
Background
HEALTHCARE DELIVERY SYSTEM
According to Stanhope, ‘Health care delivery system is referred as the total of resources that a population distributes in the organisation and delivery of its health services.’ This includes all public and personal services performed for the motive of maintaining or recovering health.
Objectives of Healthcare System in India The healthcare system of any country is designed based on the requirement and need of the country. As mentioned above the India is ranked at 154th among 195 countries on the healthcare index. Based on this the objectives of Healthcare system are set as follows: (1) In order to improve the health status of the people
(2)In order to improvise the social justice equity in health status of the entire population
(3)In order to reduce the total economic burden of health care
(4)In order to raise and combine the resources that are accessible to deliver health services.
Principles of Healthcare System The following principles were considered as a solution to the challenge of sustaining health care systems in India.
The healthcare system should supports a cohesive and well co-ordinated health care services
A good healthcare system should not charge fee-for-practice
The healthcare system should support the idea of pre-paid group practice
The prime focus should be to have community-based and community-controlled health care system
Primary Health Care should be available to everyone.
Encouragement of health as a fundamental human right.
The poor and the elderly should not be ignored of healthcare
Universal health insurance should be encouraged.
CONCEPTS OF HEALTH CARE SYSTEM
Comprehensive Health Care
Primary Health
Care
Basic Health
Services
COMPREHENSIVE HEALTH CARE This concept of healthcare was defined by the Bhore Committee and had the following criteria:
To provide preventive ,curative and promotive health services
Proper Co operation between the people, the profession and the service.
Health is available to everyone irrespective of their economic status
Pay attention to the vulnerable and weaker sections as well
A healthy work environment should be present in all healthcare units.
BASIC HEALTH SERVICES
This term was used by UNICEF/WHO in their joint health policy.
A network of peripheral, co-ordinated, and intermediate health units that are capable of performing effectively.
Functions essential to the health of an area should be performed and assurance of the availability of professionals and materials should be there
PRIMARY HEALTH CARE
It was inspired by the concepts of Bhore committee
It came into existence in 1978 after an international conference at Alma –Ata (USSR)
Primary healthcare was defined as a method where health care made universally accessible to individuals and acceptable to them, at a cost they can afford
HEALTH CARE DELIVERY SYSTEM
PUBLIC HEALTH SECTOR
INDIGENOUS SYSTEMS OF MEDICINES
NATIONAL HEALTH PROGRAMMES
PRIVATE HEALTH SECTOR
1.PUBLIC HEALTH SECTOR
This includes the following four :
Primary Health Care
Hospitals/Health Centres
Health Insurance Schemes
Other agencies -Defence Medical Services
2. PRIVATE SECTOR
Private hospitals, dispensaries
Nursing homes , General practitioners and clinics
3. INDIGENOUS SYSTEMS OF MEDICINES
AYUSH- Ayurveda, Yoga, Unani , Siddha, Homeopathy
Unregistered practitioners
4.VOLUNTARY HEALTH AGENCIES
-INDIAN RED CROSS SOCIETY
-INDIAN COUNCIL FOR CHILD WELFARE
5. NATIONAL HEALTH PROGRAMMES
-National Malaria Eradication Programme
-National Filaria Control Programme
– National Tuberculosis Programme
-National Leprosy Eradication Programme
PRIMARY HEALTH CARE SYSTEM
Primary health care includes health care services that are made universally accessible, acceptable and affordable to all.
At Village level:
(1)Village Health Guide Scheme
encourage people’s participation in the care of their own health.
someone from the permanent residents of the local community who is capable of reading ,writing and is able to spare at least 2 to 3 hrs every day
After a short training, they are given responsibilities like treatment of simple ailments, giving first aid, family planning ,health education and sanitation.
(2) Local Dais
An initiative to train all local dais in the country to improve their knowledge and skills in maternal health, child health and sterilisation
They are trained for 30 days,
Each dai conducts minimum 2 deliveries under the guidance and supervision
They are provided with delivery kit and a certificate
(3) Anganwadi Worker
-One anganwadi worker is appointed for a population of 1000
-Usually a female,She undergoes training in health, nutrition and child development
(4)ASHA: Accredited Social Health Activist
-There main aim is to create awareness on health
-They counsel women on maternal and child health ,prevention of communicable infections including RTI/sexually transmitted infection, family planning
-They provide primary medical care for diarrhoea, fevers and first aid.
At Subcenter Level
– One sub-centre is allotted for every 5000 population in general
– One for every 3000 population in hilly, tribal and backward areas.
– It is managed by one male and one female multipurpose health worker
– Main functions include mother and child health care, family planning and immunisation
At Primary Health Centre Level
-it is an effort to provide comprehensive health care to the rural population.
-One PHC allotted for every 20,000 population in hilly, tribal and backward areas.
-A medical officer along with 14 paramedical and other staff is included
-It is a referral unit for 6 sub-centres.
Functions of primary health centres
Medical care
MCH and family welfare
Safe water supply and basic sanitation
Prevention and control of communicable diseases
Collection and reporting of vital statistics
Health education
National health programmes
At Community Health Centre Level
It is the secondary level of health care, constituting the First Referral Units (FRU) .
It caters to 80,000 population in tribal/ hilly areas
It caters to 1,20,000 population in plain areas.
30 bedded hospital providing specialist care in medicine, obstetrics and gynaecology, surgery and paediatrics.
NATIONAL HEALTH POLICY 2017
National Health policy 2017 is India’s third policy.
Previously it was released in 1983 and 2002.
The goal of the National Health policy 2017 is to achieve the highest possible level of good health and well-being for all Indians.
KEY POLICIES :
NATIONAL HEALTH ASSURANCE MISSION, 2014
National Health Assurance Mission is the effort of government to reduce the out of pocket expenditure on health care by the population.
It was announced in 2014. According to it,Public health is a state subject and is a matter of great importance.
The mission aims at:
providing diagnostic services , free drugs, and insurance for serious problems for India’s 1.3 billion people.
covering all aspects of health care including primary, secondary and tertiary healthcare.
Under National Health Mission, financial help is provided to all the States and Union Territories for improvising its health care systems including benefits to those who use the following services in public health facilities:
Universal Immunisation of children against 7 diseases,
Family Planning services,
Maternal and Reproductive Health Services
Child Health services
Adolescent Reproductive and Sexual Health (ARSH) services,
Investigation and treatment for Malaria, Kalaazar , Tuberculosis , Leprosy, Filaria, Dengue, JE and HIV/AIDs.
Non-Communicable diseases services
Cataract surgery for Blindness control
HEALTH BUDGETING IN INDIA
The vision of the National Health Policy is directed towards doubling the government expenditure for health.
This means the government will switch from the current 1.15 % of the GDP to 2.5 % by 2025.
The recent budget allocation for health is Rs 52,800 crore for the year 2018/19.
It was just 5 per cent higher than Rs 50,079.6 crore in 2017/18.
A step by step effort by the government is visible from comparing the budget of 2016/17 to 2017/18 which was almost 25 percent higher.
In order to implement the National Health Policy 2017(as stated above) by year 2025 , both central and state government need to increase the total allocation for health to Rs 800,000 crore, instead of the meagre Rs 200,000 crore.
The budget of central government alone needs to increase at least 20 percent every year for the next 7 years.
Further, the government is further being very proactive with the idea of establishing 1.5 lakh Health and Wellness Centres .
These centres will bring health care system accessible and provide comprehensive health care.
A budget of Rs 1,200 crore has been allocated for these centres.
Along with this, a flagship of National Health Protection Scheme will also be launched to cover 10 crore poor and vulnerable families.
This will provide coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalisation.
PURPOSE OF THE CURRENT STUDY
On a positive side, India is trying to increase and improvise the budgeting and resourcing in the department of healthcare, but there are many things we are still lacking at.
A study conducted by IndiaTimes found out that 27 crore people across 64 districts in 13 states lack a single blood bank.
With a total of 2,708 blood banks, there is one blood bank for whooping 46.5 lakh Indians.
India has a total of registered 9,38,861 doctors, which comes down to 7 doctors per 1,000 people
As stated by the data from Central Bureau of Health Intelligence (CBHI) in 2015, Bihar and Maharashtra have the worst doctor to patient ratios.
From the data stated by Ministry of Family and Health Welfare, One government hospital bed accounts for 1,833 people on an average.
The Rural Health Statistics (RHS) state that India has a total of 25,310 – Primary Health Centres (PHCs) 5,398 – Community Health Centres (CHCs) 765 – District hospitals
The data from the union health ministry till 31st March 2015, states that the conditions in India require to have 29,337 PHCs but it only has of 25,310.
There is a shortfall in each sector of the health care delivery system Require Current Count Shortfall PHC 29,337 25,310 22% CHC 7,322 5,396 32%
Further there is uneven distribution of health.According to WHO, the proportion of higher income class with access to free healthcare and proportion of lower income classes getting free health care is 22 and 17.33 percent respectively.
The following statistics show that we need to understand the access, acceptability and affordability of health care for the normal public.Even if the healthcare services are available, they are being unevenly and unethically distributed between the rich and the poor
Methodology
STUDY OBJECTIVES:
Primary objectives:
To Assess the awareness and knowledge of the Indian community regarding health care policies and delivery
Secondary objectives:
To draw some conclusions about future strategies to enhance knowledge of the community regarding health care policies and delivery and how they can exercise there rights to avail them.
STUDY DESIGN:
A cross sectional observational study has been conducted.
Stage 1
This stage involved collection of demographic and other data about the knowledge and awareness of people regarding health care policies and delivery.
A total of 422 applicants have filled the web based google forms.
The forms were filled by people of different socio demographic characters, based on gender, age, education qualification and income.
Stage 2
This stage involved a focused group discussion regarding the same from 8 people each in 2 rounds.
The first round had people from rural setting while the other round had people from urban setting
They were asked to discuss there opinion on health care delivery system and services
STUDY SITES:
Study has been undertaken via two mediums:
Phase 1 was conducted via google forms and the responses were taken from all over India
Phase 2 was conducted at 2 sites -The site to take FGD of people from rural setting was Sewalaya Charitable Trust, Saket, New Delhi. -The site to take FGD of people from urban setting was Sainik Farms,New Delhi.
STUDY ENROLMENT CRITERIA:
Phase 1
422 people from Indian community who were 18 years and above and were literate were included in the study.
Phase 2
Total 16 people
8 from rural setting and 8 from urban setting were taken in phase 2 of the study.
STUDY POPULATION CRITERIA:
Participant Inclusion criteria (for PHASE 1)
Age: 18 years and above
Gender: Any
Education: minimum litterate
Income(Monthly): Any
Participant Inclusion criteria (for PHASE 2)
Age: 18 years and above
Gender: Any
Education: Any
Income(Monthly): Any
Participant Exclusion criteria (for PHASE 1)
Age: less than 18 years
Education: not literate enough to understand and fill form
Never availed any sort of medical services in Private and Public hospital in India
Not Indian citizen
Participant Exclusion criteria (for PHASE 2)
Age: less than 18 years
Cannot communicated in Hindi for FGD
Never availed any sort of medical services in Private or Public hospital in India
Not Indian citizen
PHASE 1 : WEB BASED SURVEY FORM
Gender: ____________ Location:_________________
Age: a) 18-35 years b) 36-55 years c)older than 55 years
Education Level: a)Post-graduate or professional degree b)Graduate degree c)Higher secondary certificate d)Middle school certificate e)Literate, less than Middle school certificate f)Illiterate
Income(Monthly): a) Unemployed b)Less than 20k c) 20-50k d) Above 50k
Q1) Is Health a fundamental human right in India?
Yes b)No c)Don’t Know
Q2) Are you aware about National Health Policy 2017?
Yes b) No
Q3)Are you aware about universal health assurance mission? a)Yes b) No
Answer the following statements(Q4-Q10) based on if you agree with it or disagree
Q4)The government should guarantee health care access for all citizens
Agree b) Disagree
Q5)The government should regulate the prices of health care services a) Agree b) Disagree
Q6) Health care services would improve if the government had no involvement in health care
a) Agree b) Disagree
Q7) All citizens should have access to the same standard of medical care without regard to their financial means
a) Agree b) Disagree
Q8)All children should have access to the same standard of medical care without regard to their parents’ financial means a) Agree b) Disagree
Q9)Access to health care is a privilege, not a right. a) Agree b) Disagree Q10) Addressing health care policy issues, as important as that may be, falls outside the scope of the professional obligations of a physician. a) Agree b) Disagree
Q11)Which amongst the following should be practiced the most in-order to improve health care delivery in India?
a)Insurance companies should lower their profit margin b)Drug companies should lower their prices
c)Hospitals should decrease their operating costs
d)Hospitals should not be operated for profit
Q12)Which amongst the following hospitals would you go incase of any problem? a)Private hospital b)Public Hospital
Which amongst a private and public hospital would you choose for the following qualities?
Q12) Satisfaction with the time given by the doctor a)Private hospital b)Public Hospital
Q13)Satisfaction with explanation about treatment plans a)Private hospital b)Public Hospital
Q14)Effectiveness of treatment a)Private hospital b)Public Hospital Q15)Explanation about medication purpose and side effects a)Private hospital b)Public Hospital Q16)Explanation about tests required, if any a)Private hospital b)Public Hospital
Q17)Satisfaction with paramedical staff
a)Private hospital b)Public Hospital
Q18)Availability of drinking water, adequate seating, etc. a)Private hospital b)Public Hospital
Q19)Satisfaction with cost of treatment a)Private hospital b)Public Hospital
PHASE 2 : FOCUSED GROUP DISCUSSION