Kurukshetra November 2018 - Rural Health (Part 2) (Download PDF)


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Present Situation: Govt. facilities face different set of challenges in ensuring quality of care: huge patient load, lack of accountability, absenteeism, management gaps & fixed salary based payment incentives.

  • Current legal framework for regulation of medical services is under Clinical Establishment (Registration & Regulation) Act, 2010, Drugs & Cosmetics Act, 1940 & various Acts governing profession such as Medical Council of India (MCI) & other related professional councils.

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Rural Health - Kurukshetra November 2018 (In English)

Dr. Manishika explained Kurukshetra November 2018: Rural Health

What is likely impact of Ayushman Bharat?

  • Another lever to induce quality improvement by providers is thru payment based incentives.

  • For instance, NHA has announced that National Accreditation Board for Hospitals (NABH) accredited providers will be paid 15 % higher and entry level NABH facilities will be paid 10 % higher for same package than non-accredited ones.


  • Improving quality of health care at system level requires focus on governance issues, improving public-sector mgmt. , building & augmenting institutional capacities as well as promoting culture of data-driven approach.

Ayushman Bharat-PMJAY: India’s Answer to Universal Health Care

  • Health sector is amongst largest & fastest growing sectors, expected to reach US $280 billion by 2020.

  • India’s health sector faces immense challenges. It continues to be characterized by high out-of-pocket expenditure, low financial protection, low health insurance coverage amongst both rural & urban population. It is matter of grave concern that we incur high out-of-pocket expenditure on account of health & medical costs.

  • 62.58 % of our population has to pay for its own health & hospitalization expenses & are not covered thru any form of health protection.

  • AB-PMJAY aims to reduce financial burden on poor & vulnerable groups arising out of catastrophic hospital episodes & ensure their access to quality health service.

  • It seeks to accelerate India’s progress towards achievement of Universal Health Coverage (UHC) & Sustainable Development Goal – 3 (SDG3).

📝 2 major initiatives in health sector:

  • Health & Wellness Centre:

    • National Health Policy, 2017 has envisioned Health & Wellness Centres as foundation of India’s health system.

    • Under this, 1.5 lakh centres will bring health care system closer to homes of people.

  • National Health Protection Scheme:

    2nd flagship programme under Ayushman Bharat is National Health Protection Scheme, which will cover over 10 cr. poor & vulnerable families (approx. 50 cr. beneficiaries) providing coverage upto 5 lakh rupees per family per year for secondary & tertiary care hospitalization.

    Image of National Health Protection Scheme

    Image of National Health Protection Scheme

    Image of National Health Protection Scheme

  • This initiative would ensure that there is at least 1 Medical College for every 3 Parliament Constituencies & at least 1 Govt. Medical College in each State of country.

    Major Impact

    • In-patient hospitalization expenditure in India has increased nearly 300 % during last 10 years.

    • More than 80 % of expenditures are met by out of pocket (OOP).

    • Rural households primarily depended on their ‘household income/savings’ (68%) & on ‘borrowings’ (25%), urban households relied much more on their ‘income/savings’ (75%) for financing expenditure on hospitalizations & on (18%) borrowings.

    • OOP expenditure in India is over 60 % which leads to nearly 6 million families getting into poverty due to catastrophic health expenditures.

    • AB-PMJAY will have major impact on reduction of OOP expenditure on ground of:

      • Increased benefit cover to nearly 40 % of population, (poorest & vulnerable)

      • Covering almost all secondary & many tertiary hospitalizations (except negative list).

      • Coverage of 5 lakh for each family (no restriction of family size).

    • This will lead to increased access to quality health & medication.

    • Unmet needs of population which remained hidden due to lack of financial resources will be catered to.

    • This will lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity & efficiency, job creation thus leading to improvement in quality of life.

    • Govt. argues that poorest & vulnerable will have health insurance. Scheme will initially cover nearly 40 % of population.

    • Barring few procedures, scheme covers almost all secondary & many tertiary hospitalizations, which in normal circumstances, bankrupt poor people.

    • This may lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity & efficiency & job creation, leading to improvement in overall quality of life.

    • 👌 Helpline Number of Ayushman Bharat Yojana – 14555


  • Scheme is innovative & path-breaking in history of public health in India, which may have transformative impact if implemented in effective & coordinated manner.

  • Scheme will help in enriching database of hospitals registered w/Registry of Hospitals in Network of Insurance (ROHINI) System & human capital captured under National Health Resource Repository (NHRR) project.

  • This can later be used innovatively for improvement of access to & quality of healthcare services in country.

Poshan Abhiyan: Towards Holistic Nutrition

  • 👌 Acknowledging malnourishment as major challenge, POSHAN Abhiyan was launched by PM in March, 2018 w/aim of improving nutritional outcomes for children, pregnant women & lactating mothers.

  • For instance, stunting has declined from 48 % in 2005 - 06 to 38.4 % in 2015 - 16.

  • Underweight prevalence has reduced by 0.68 % points from NFHS-3 to NFHS-4.

  • According to National Family Health Survey-4, over 1/3rd of all under-5 children are stunted (low height for age), every 5th child is wasted (low weight for height) & more than 50 % children are anaemic.

  • 2017 report published by Save the Children indicates that over 2/3rd of world’s stunted children live in 10 countries.

  • In list of 10 countries India is ranked at 1st number w/estimated 48.2 million stunted children.

  • World Bank estimate indicates reducing stunting in country can raise GDP of India by 4 - 11%.

  • Global Nutrition Report estimates return USD 16 for every USD 1 spent on health & nutrition.

  • States which have max. population of undernourished people is Bihar & MP.

  • Problem of overweight people is more acute in AP, Sikkim & Goa.

  • Anemia levels in women range from 45 % in Karnataka to 63 % in Haryana.

Determinants of Malnutrition

  • There are several underlying determinants of malnutrition including lack of access to health services, safe drinking water, sanitation & household food security as well as unhealthy behavioral practices.

Pillars of Abhiyan

  • 👌 One of most imp. pillars of POSHAN Abhiyan is programmatic convergence for enabling development of shared understanding of roles & responsibilities as well as mutual accountability mechanisms across sectors.

  • For instance, agriculture plays crucial role in enabling availability of nutritious food.

  • Another key aspect of Abhiyan is focusing on 1st 1,000 days of child’s life by providing health & nutrition services in intensive manner.

  • Studies indicate that 80 % of brain development occurs during this stage.

Image of Pillars of Abhiyan

Image of Pillars of Abhiyan

Image of Pillars of Abhiyan

  • To enable this, Abhiyan will focus on providing joint incentives to motivate frontline workers for improving nutrition outcomes.

  • Incentives will be provided to states & districts based on improvements to nutritional status of their respective populations in form of both high absolute levels of achievement as well as positive changes in key indicators.

  • Greater flexibility will be given to states so that they can focus on health & nutrition interventions that best address their needs.

  • Sub-group of Chief Ministers set up to review Centrally Sponsored Schemes had universally recommended flexible component in every scheme besides decentralized decision making by states on pattern of Rashtriya Krishi Vikas Yojana.

  • 👌 Another imp. pillar of POSHAN Abhiyan is enabling scaling up of innovative & impactful service delivery models across states.

Educating Communities

  • Educating communities abt. nutritious food, effective & hygienic food preparation & storage as well as improved water & sanitation is imp. for enabling them to make more informed choices.

  • Recent World Bank report estimates that abt. 2/3rd of workforce in India earns on average 13 % less than what they would have if they had not been stunted during childhood.

  • Another World Bank study calculates that malnutrition costs India’s GDP b/w 2&3 % points every year.

Health Care for India’s Remote Tribes

  • W/population of more than 10.2 cr. , India has single largest tribal population & at present, there are 705 Scheduled Tribes groups & among them 75 are considered as Particularly Vulnerable Tribal Group (PVTG) & each group vastly different from other from ethnic & cultural stand points.

  • Geographically they are spread in almost all states & union territories but greatest numbers is in MP (12.23 million, or 20.3 % of state’s population), Maharashtra (8.58 million or 8.9%), Odisha (8.15 million or 22.1%)

  • By proportion, population of states in North East have greatest concentrations of STs, i. e. , 31 % of population of Tripura, 34 % of Manipur, 64 % of Arunachal Pradesh, 86 % of Meghalaya, 88 % of Nagaland & 95 % of Mizoram are scheduled tribes.

  • Other heavy concentrations are in Dadra & Nagar Haveli & Lakshadweep (94%).

Map of concentrations are in Dadra & Nagar Haveli & Lakshadweep

Map of Concentrations Are in Dadra & Nagar Haveli & Lakshadweep

Map of concentrations are in Dadra & Nagar Haveli & Lakshadweep

  • Most tribal people are poor & they live in remote rural hamlets in hilly, forested or desert areas where illiteracy, tough physical environments, malnutrition, inadequate access to potable water, lack of personal hygiene & sanitation make them more vulnerable to disease & as result they have worse health indicators than general population.

  • Cultural practices such as high level of consanguineous marriages among tribes may lead to hereditary diseases such as sickle cell anaemia, G6PD & thalassemia.

  • Some of highest rates of tuberculosis in country have been reported from Sahariya tribe of MP. Deaths due to malaria occur disproportionately among Tribals.

  • Kyasannur Forest Disease (KFD) is reported to be looming threat to forest tribes w/occasional deaths.

- Published/Last Modified on: November 26, 2018


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