Yojana Feb 2014- Summary
Introduction of the magazine
This month’s magazine is focusing on public health. It is also a special article on strategies for sustainable progress.
Topic number one: financing India’s quest for universal health coverage
what this Universal Health Coverage (UHC)?
UHC is about people having access to needed health care without suffering financial hardship, thus encompassing improvements in access, quality and financial protection.
Health as per 12th five year plan?
12th five year plan lays out its long-term objective of establishing a system of Universal Health Coverage (UHC).
Various problems cited
- low levels of financing
- accountability issues in the public delivery system
- persistent dominance of out-of-pocket spending
what is out-of-pocket spending? Anything important about this?
- Out-of-pocket spending simply means the money spent by the patient directly to the doctor from his own pocket for getting treated.
- India is the only country which has highest percentage of out-of-pocket spending.
- Paying out of pocket can also lead to West Indies since insurers can negotiate lower fees with healthcare providers than individuals. Increased reliance on out-of-pocket spending means that only those who can afford to pay can access care of reasonable quality
- India had allotted around 4.1% of the GDP to health sector in 2008-2009
- India though has 17% of the world population, it spends only 1% of the worlds total health expenditure on this population.
- Share of health spending has not kept pace with the country’s dynamic economic growth (it was 1.8% of the GDP in 2001-2002)
four main sources of the health finance and delivery in India
- out-of-pocket spending is very high. It is the most important reason for impoverishment in India.
- The second is the tax financed direct public delivery which in principle is available for all of India’s population.
- The third segment consist of social insurance schemes for formal private sector workers and government employees
- the fourth segment is voluntary private insurance (PHI) which emerged in the late 1980s but has grown rapidly in 2000s.
Features of the health programmes in India
- what about design for expansion of health coverage (starts with rural area and poorest segment of the population first)
- rapid scaling up of population coverage in a short period of time
- there are several commonalities between the various health programs that is insured they all a matter extending health coverage and improved financial protection to the poor and other vulnerable groups in the country.
Two prominent national programs in relation to health
- National Rural Health Mission (NRHM) ,program by the Ministry of health and family welfare (now changed to national health mission and being further in urban areas)
- Rashtriya Swasthya Bimah Yojana (RSBY), program by Ministry of labour and employment.
- In addition several state health programs are also being run. Famous among these are Rajive Aarogyasri scheme (of Andhra Pradesh) & Rajeev Jeevandayee (of Maharashtra)
- it is a flagship initiative of the Ministry of health and family welfare
- aimed at expanding health coverage in the country
- it supplements and strengthens the state owned public health systems by providing additional resources with a focus on rural areas primary care and public health problems.
- Also leverages this financial support to facilitate the creation of institutional mechanisms that enable some degree of financial autonomy and a faster flow of funds
- it is also a component called Janani Suraksha Yojana, which offers conditional cash transfer to poor women for availing free institutional maternity services created under NRHM.
- by 2009 about 19% of the Indian population has been covered under different government-sponsored health insurance schemes.
- Accounting for private insurance and other forms of coverage more than 25% of the population had access to some form of health insurance in 2010.
Does India have fiscal room to finance universal health coverage?
- India definitely doesn’t have that amount of money that it could support universal health coverage.
- India has three options: 1) increase the revenues that is taxes and get the money required for universal health coverage 2) government can reprioritise health (example by reducing expenditure on subsidies) 3) India can opt for option one an option two both
- financial constraints and augmentation among the health programme remains
- but it is clear that the programs have their area focus clearly marked out (primary care in the case of NRHM, secondary care in the case of RSBY and tertiary care in the case of state health insurance schemes)
- thus if these programs could further evolved to a state of close coordination and similarly defined populations to be covered and with smoke linkages they could contribute to more seamless comprehensive coverage for primary secondary and tertiary care.
- Preventive interventions and effective case management for noncommunicable diseases at the primary care level can contribute significantly introducing the need for hospitalisation thereby simultaneously improving quality of life for the beneficiaries and containing the cost of hospitalisation programs.
Topic number two: achieving universal coverage in India: resource use and policy considerations
international examples of universal health coverage
- in 2001 the government of Thailand launched a health insurance scheme that provides is initially free coverage to large number of people in the agriculture and informal sectors in addition to groups in the organised or formal sector. As a consequence almost its entire population was covered by health insurance.
- In the last two decades China reduced its funding for the health sector because of its pro-market reforms. But China launched to insurance funds - one for the popullaton in urban areas and the another for the rural areas. Recent estimates suggest that these schemes cover almost the entire population of China.
Various concerns about universal health coverage
- first, overall cost of healthcare have a tendency to rise over time. It especially because of the rapid technological advancement and the new treatments which are coming in.
- Second, in the absence of insurance or ready availability of subsidised care in public facilities the burden of this rising cost will fall primary opponent households in the form of out-of-pocket payments
- Third, there are issues of resource wastage and equality involved. For example the wastage caused by the out-of-pocket payment.
For major challenges in designing and implementing a strategy of universal coverage
- how much will universal coverage cost?
- What will it cover
- who will it cover
- who will provide the services
- there is little doubt that expanding coverage will require a much larger allocation of public resources than in the past
- also from the international examples we have seen that many of the countries who had gone for universal health coverage that not able to support it because of the lack of funds
what benefits will it cover percent mark
- should insurance cover the cost of all types of illness? Clearly resource limitations will not permit this.
- Administrative cost can be extremely high for processing multiple small claims.
- There is also the risk that fully financing of all services leads to vestige due to over use of subsidised healthcare. People could end up seeking care for minor aches and pains, cough and colds and so on.
- At the same time we do want people to use preventive care (example immunisation, regular medical checkups, antenatal and postnatal care) that can lower the risk of later complications and hospitalizations.
International example of how to choose
- Mexico offers an example of how to choose services to be covered.
- They divided healthcare services into three 1) those intended for preventive purposes 2) to care for relatively rare conditions that are expensive to treat (example cancer) 3 intended to treat common conditions (fever, injuries, etc.)
- this approach helps to offer the most health benefits per rupee
who will it cover?
- Policy choice about the benefits to be covered is one strategy when resources are scarce.
- Alternatively, the government target some groups for greater subsidies than others to conserve resources.
- Most important point is Universal coverage did not translate into universally free coverage.
- Problems in India for selecting the beneficiary group: we don’t have effective identification system for identifying those people who really need health coverage because of their poor economic position.
Who will provide healthcare services?
- Financing is not the sole issue.
- Expanding health insurance coverage will raise the demand for healthcare services in India by making care more affordable.
- This draws attention to the supply-side issues. The three issues have been discussed below.
- First, we need to assess the appropriate role of the private and the public sectors in the context of the increased government financial contributions to the health sector. Private sector is more responsive to consumer needs as compared to the public sector. Public sector should be brought at par with the private sector. (Public sector lags behind private sector mainly because of the unavailability of the funds. Also public sector is hampered by its administrative and financial structures)
- Secondly, the organisation of primary care and hospital care needs improvement. Currently, individuals can directly visit hospitals and specialist completely bypassing healthcare services at the primary level. Apart from long queues in major hospitals, this results in inefficient use of expensive specialist time.
- Third funding the reach of health services to rural and remote areas is hindered by the limited availability of the providers there. (Note it is a matter of debate that whether government doctors should be allowed to practice privately, outside of work hours to make rural locations attractive.
Topic number 3: high prices of patented medicines in India: can we do anything about it?
- in 1972, India abolished product patent protection in pharmaceuticals.
- It’s helped India to become a major player in the global pharmaceutical industry
- but from January 1, 2005, drug product patent protection has been reintroduced in India to comply with the requirements under the agreement’s on Trade Related Aspects of Intellectual Property Rights (TRIPS) of the World Trade Organisation (WTO).
What exactly is a patent right?
Patent rights are the rights which exclude others from producing and marketing the product for which someone has got a patent.
Economic rationalism for granting patents
- it will stimulate investment for research for innovation
- the basic presumption is that developing new drugs is expensive. It is argued that without patent protection, others may be able to imitate new products thereby limiting the innovators ability to fill the research and development cost
- a delay in imitation through patent protection would stimulate research and development for innovation.
Negative impacts of patents
- there is no competition among the companies for producing a particular product. So there is reduced efficiency.
- It leads to higher prices of the products.
- It also leads to less access to the products
About TRIPS agreement
TRIPS agreement not only helps for the protection of rights of patentee’s but also ensures that it provides sufficient rights to member countries to take steps to prevent abuse of patent and other intellectual property rights.
Flexibility provided by TRIPS to tackle the negative consequences of product patents protection:
- exemptions from grant of patents in certain cases
- compulsory licensing
- India has used the first provision of ‘exemptions’ very efficiently by adding Section 3 (d) India amended patents act when reintroducing product patents in pharmaceuticals in 2005.
- But India is very weak in the case of compulsory licensing. Till now that he should only one compulsory license. It shows India’s plight in the case of using the second option.
Patents under TRIPS
- patentee is given for a limited time period, currently for 20 years under trips.
- That is after 20 years other forms can also make the same product.
- But companies particularly in the pharmaceutical industry are resorting to illegal practices. The one called “evergreening”
- Evergreening is the method by which a particular company tries to get a new patent for the same product after the expiry of 20 years. This is accomplished by making small changes in the ingredients of the medicine.
- While it is allowed in USA, it is definitely not allowed in India.
- Section 3 (d) tries to regulate such abuses of the patent system. Under this the mere discovery of a new form of unknown substance which does not result in the enhancement of the known secrecy of that substance is not patentable.
- In short evergreening is not allowed in India.
About supreme court decision in Novartis case
- Supreme Court decision is consistent with strings and has been arrived at not been really but by following transparent and internationally accepted legal process.
- Moreover it has helped other developing countries to stop Evergreening.
What is compulsory license?
- The compulsory license is an authorisation by the government to non-patentee’s to use the patent for example to manufacture and sell the patented medicine without or against the consent of the patentee on payment of royalties.
- Good points: it Indian companies are given licences to produce a patented drug under compulsory license, competition among manufacturers would rise down prices but the royalty paid to the innovators would continue to provide funds and the incentive for research and development.
- So we can see that compulsory license does not hamper research and development.
Various grounds for application of compulsory license
- grounds of reasonable requirements of the public have not been satisfied or
- the product is not available at the reasonably affordable price
- the patented invention has not worked in the territory of India
- Canada has the most effective strategy for compulsory license.
- It is straightforward transparent and fast.
- A patent holder will naturally be opposed to any compulsory licenses. The Canadian experience shows us how the practice and the procedures can be such that the patentee’s have practically no unfortunately to delay or prevent the grant of compulsory licenses.
Indian case of compulsory license
- the entire process is excessively legalistic.
- The procedure is open-ended without any time limit imposed for the grant of compulsory license.
- It provides the patentee’s the opportunity to buy time through litigation.
- Hence there is much delay in giving a compulsory license and litigation goes on.
- No presence of automatic route for issue of compulsory license.
Another way for controlling high prices by patents
- Another flexibility the India can utilize is to directly control the price of patented drugs. Price control is not forbidden under trips or any other agreements under the WTO.
- But there is problem with the price control. It is not good as compulsory license.
- If price control is used the patentee companies would simply not sell their products in India. Also it will hamper the space to generating companies which is vital for the long-term sustenance.
Topic number 4: India Backbone Implementation Network (IBIN)
- IBIN project was launched on April 19,2013 by the planning commission.
- The purpose of it is to improve implementation of policies, programs and projects which the 12th five year plan has identified as of crucial importance.
- The ultimate objective is to accelerate inclusive and faster growth.
- It has been launched in view of the finding that several projects and schemes have been facing bottlenecks at the implementation level in districts, state and the Central level.
- Need has been emphasised to convert confusion in the coordination, contention into collaboration and intention in the implementation.
Topic number 5: reverse mortgage
- reverse mortgage is alone that enables a borrower to convert part of the equity in their home into cash.
- It is also called Home Equity conversion loans.
- If a senior citizen owns a home and has equity in it, he is entitled of the loan.
- In reverse mortgage no principle or interest payments are required on the home while the borrower occupies the property.
- Repayment is needed if the borrower sells the home or moves out of the property.
- It is generally given to people having age more than 62 years.
- Reverse mortgage is a means to help aged people with limited income to use the money they have put into their home to pay off debts and cover their other necessary expenses.
Topic number 6: Various Important Health Schemes
National rural health mission
Launched in 2005, National rural health Mission is an overreaching project information more that strives to provide effective healthcare to rural masses in the country with a focus on states with poor public health indicators and all weak healthcare infrastructure. The programs under this can be broadly be categorised into two: reproductive and child health programs (RCH) and national disease control programme. RCH programs address the issues and challenges relating to maternal and child health care through a range of initiatives.
Janani Suraksha Yojana (JSY)
Launched in 2005 as a key component of national rural health mission and being implemented in all states and union territories with special focus on low performing states, it aims to reduce maternal mortality and neonatal mortality by promoting in institutional delivery of were pregnant women. Under eight the pregnant woman from the rule BPL family are provided Rs. 1400 as incentive to use government healthcare facilities and also to cover travel costs and other expenses.
Janani-Shishu Suraksha Karyakram (JSSK)
It aims to provide free and cashless healthcare services to pregnant women including normal deliveries, Caesarean operations (up to 30 days after birth) in public health institutions in both rural and urban areas.
Navajat Shishu Suraksha Karyakram (NSSK)
Launched in 2009, it attempts to impart special training to healthcare providers at the district hospitals, community health centres and primary health centres in the interventions at birth aimed at significantly reducing infant mortality ratio. The program is a part of the policy of embedding child health strategy has an integral part of maternal health.
Rashtriya Kishor Swasthya Karyakram (RKSK)
Launched on 7 January 2014, it is the nation’s first comprehensive adolescent health programme. The programme is committed at promotion of adolescent health mission across India and would address the health needs of 24 million adolescents constituting 21% of total population in the country.
National Disease Control Programmes
Noncommunicable diseases like cancer diabetes cardiovascular diseases, and chronic obstructive pulmonary diseases are on the rise in the country to the change in lifestyle. Communicable diseases such as tuberculosis, leprosy, vector borne diseases, HIV or AIDS among others also continue to be a major public health challenge. These endemic diseases result in high morbidity, mortality and adverse socio-economic impact. Therefore national level programs on diseases have been implemented with a renewed vigour and focus under national rural health mission.
National vectorborne diseases control program (NVBDCP)
A comprehensive program for the prevention and control of vectorborne diseases. It covers diseases like malaria, filarial, kala-azar, Japanese encephalitis, dengye and Chikangunya.
Revised National tuberculosis control programme
Launched in 1997 and implemented in a phased manner, revised National tuberculosis control programme - an application in India of directly observed treatment short-course i.e. DOTS is a revamped strategy to control to break losses with the objective of securing at least 85% of new sputum positive TB patients.
National leprosy eradication program
With the use of multidrug therapy, under this program, introduced in 1983 India achieved the goal of elimination of C defined as less than one case per 10,000 at the national level in December 2005.
National AIDS control programme
It has the overall goal of hunting and reversing the epidemic in India over the five-year period it places highest priority on preventive efforts while at the same time seeking to integrate prevention wiki support and treatment.
National mental health programme
It was introduced in 1982 with the objectives of ensuring availability and accessibility of mental health care for all in the foreseeable future particularly to the most vulnerable and underprivileged sections of the population. It also aims to promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.
Pradhan Mantri Swasthya Suraksha Yojana
It was launched in 2006 to which the huge In the accessibility of healthcare services in the rural and urban areas. Under the program, institutions in the model of all India Institute of medical science would be set up along with the extensive upgrading of 13 government medical colleges.