Choubey notes, that maternal deaths, being a rare event, require large sample size to provide robust estimates. Registrar General of India uses the Sample Registration System (SRS) to provide estimates on maternal mortality which does not generate data on yearly basis.

In order to enhance the SRS sample size, therefore, the results are derived by pooling the three years data, he says.

As per the report of Sample Registration System (SRS) released by Registrar General of India (RGI), Maternal Mortality Ratio (MMR) of India has shown a gradual decrease. For every 100,000 live births, there were:
 

• 167 maternal deaths in SRS 2011-13,
• 130 maternal deaths in SRS 2014-16,
• 122 maternal deaths in SRS 2015-17.

As per the state-wise data provided in the answer, Uttar Pradesh had the most number of maternal deaths for all three SRS periods. For the 2015-17 period, Uttar Pradesh saw 12,340 maternal deaths, 2.5 times more than Bihar which is next in line.

A 2014 study had noted that India contributes one-fifth of the global burden of absolute maternal deaths, but the nation experienced an estimated 4.7% annual decline in maternal mortality ratio (MMR) and 3.5% annual increase in skilled birth attendance since 1990. The total number of maternal deaths reported in the last SRS report was 37,890.

Etiology of maternal mortality

The last nation-wide survey covering causative factors that result in maternal deaths were covered by the RGI.

As per the RGI-SRS report titled “Maternal Mortality in India: 2001-2003 Trends, Causes and Risk Factors”, major causes of maternal deaths in the country are haemorrhage (38%), sepsis (11%), hypertensive disorders (5%), obstructed labour (5%), abortion (8%) and other conditions (34%) including anaemia.

WHO categorizes maternal deaths into direct, indirect and unknown/undetermined.

The whole picture

Chaubey in his response listed out steps being taken under the National Health Mission to further curb the incidence of maternal mortality in the country: Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram, Midwifery programme, etc.

Although these state efforts as well as the resultant decrease in maternal mortalities are worth noting, only looking at these statistics would obscure our view of India’s overall reproductive health conditions.

Maternal nutrition is a major concern in the country. A third of women of reproductive age in India are undernourished, and inevitably give birth to an undernourished babies, thereby perpetuating an intergenerational cycle of undernutrition. UNICEF’s State of the World’s Children 2019 (SOWC) report 38% of all Indian children below four years of age are stunted. 

Another vital issue is infant mortality. A 2018 report by the United Nations Inter-agency Group for Child Mortality Estimation (UNIGME) observed that 802,000 infants died in the country in 2017. The deaths were attributed to the lack of access to water, sanitation, proper nutrition and basic health services, despite the government’s programmes on sanitation, health and nutrition.

Related:

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These gaps “represent risks for the achievement of the key objectives of the 2030 Agenda”, the CAG said in a July 8, 2019, report.

While the health ministry proposed to increase India’s public health expenditure to 2.5% of its gross domestic product (GDP) by 2025, “it has remained within a narrow band of 1.02-1.28% of GDP”, the report said.

For this report, the CAG audited the NITI Aayog, the health ministry, the ministry of statistics and programme implementation, and 14 other ministries for preparedness to achieve SDGs. To analyse states’ performance, seven states–Assam, Chhatitsgarh, Haryana, Kerala, Maharashtra, Uttar Pradesh (UP) and West Bengal–were chosen based on their ranking on various health indices for 2015-16.

The NITI Aayog’s three-year action agenda (2017-2020) envisaged a rise in the Centre’s health budget to Rs 1 lakh crore ($14.5 billion) by 2019-20. But, the allocations have fallen short: India allocated Rs 53,294 crore ($7.7 billion) in 2017-18, Rs 56,045 crore ($8.1 billion) in 2018-19 and Rs 65,038 crore ($9.4 billion) in 2019-20, the report noted.

India’s National Health Policy 2017, framed in line with the SDGs, prescribes increasing the health expenditure of states to more than 8% of their annual budgets by the year 2020, but the seven states evaluated spent between 3.29% and 5.32% for the period of 2012-2017, according to the report.

The National Health Mission–which provides for universal access to equitable, affordable and quality health care services–was conceived as the primary tool to reach health targets: maternal mortality ratio (MMR) of less than 70 deaths per 100,000 live births, neonatal mortality rate (NMR) of 12 deaths per 1,000 live births and under-five mortality rate (U5MR) of 25 deaths per 1,000 live births.

In 2017, India’s MMR was 130 deaths per 100,000 live births, according to Census data, while its NMR was 24 deaths per 1,000 live births and U5MR was 39 deaths per 1,000 live births, as IndiaSpend reported on September 20, 2018.

Yet, allocations to the National Health Mission fell short by 13.6% in 2018-19 compared to the budget projections, according to the CAG’s report.

Source: Report of the Parliamentary Standing Committee, cited in the Comptroller & Auditor General’s report

The standing committee of parliament on health, while examining the allocations, had observed that these shortfalls would affect the strengthening of health facilities.

India’s neonatal mortality rate (24 deaths per 1,000 live births) is higher than the global average (18). Sri Lanka (8), Bangladesh (18) and Nepal (21) are better off despite having lower per capita incomes, as IndiaSpend reported on September 20, 2018.

In 2015, India spend 1% of its GDP on public health, second-lowest in the south east Asia region, according to data cited in the National Health Profile 2018. That same year, Maldives spent 9.4%, Sri Lanka 1.6%, Bhutan 2.5% and Thailand 2.9%.

State spending on health yet to increase
To reach the 2025 target of spending 2.5% of GDP on health, the National Health Policy mandated states to increase their health spending on primary care by at least 10% every year. In addition, a 4% health and education cess was also proposed which was not implemented.

The Policy, as we said, also prescribes increasing states’ health spending to more than 8% of their annual budgets by the year 2020. Yet, none of the seven states studied for this report by the CAG spent that amount by 2017.

Further, 29% of NHM funds with states were not spent over five years to 2016, as IndiaSpend reported on August 20, 2018.

Health shortages affect progress
Rural India has a shortfall of between 24% and 38% in the number of sub-centres, primary health centres (PHC) and community health centres in 28 states and union territories, data from the CAG’s 2017 audit report on reproductive and child health under the National Rural Health Mission, which seeks to strengthen the delivery of public health services in rural India, showed.

Each PHC with a load of more than 20 deliveries per month needs at least two medical officers, according to Indian Public Health Standards set in 2006. Chhattisgarh has a total of 341 doctors in PHCs, which makes for 0.43 doctor per PHC, lower than required, according to the data cited in the CAG’s report. There were “considerable” human resource shortages in Chhattisgarh and UP, the report said.

UP is one of the worst-performing states in infant and under-five mortality rankings, as IndiaSpend reported on March 16, 2017. While UP has a 30% shortage of PHCs, West Bengal has a shortage of 69%.

With a rural population of 62 million, West Bengal has one PHC for every 68,000 people–less than half the prescribed number of one PHC per 30,000 people.
 

Source: Report of CAG (No. 25 of 2017)

The population-doctor ratio in India was 11,082:1 in 2017 in government hospitals, 25 times higher than the World Health Organization recommendation of 25 professionals per 10,000 population, as IndiaSpend reported on January 28, 2019.

Dearth of data
The NITI Aayog, the government’s policy think tank and the body responsible for overseeing implementation of SDGs, and the statistics ministry in consultation with the state governments, were to prepare the National Indicator Framework, the backbone for monitoring of SDGs.

However, data for 137 of 306 national indicators were not available for 13 SDG goals, the CAG’s report said.

The framework includes 50 indicators related to health, but data for 23 of these–such as screening for cervical cancer among women and incidence of viral hepatitis–were not available, according to the report.

At both the Centre and the state levels, there was “evidence of insufficient efforts at putting in place a comprehensive indicator framework, identification of data sources, production of disaggregated data” for Goal 3 (good health and well-being), the report said.

“Better measurement, greater evidence and more informed reporting are expanding voter awareness and deepening policy debates,” as IndiaSpend reported on May 15, 2019. “This makes it imperative for central and state governments to improve the quality of public health data.”

(Ali is a reporter with IndiaSpend.)

First published on https://www.indiaspend.com/

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The skilled health workforce in India does not meet the minimum threshold of 22.8 skilled workers per 10,000 population recommended by the World Health Organisation, shows research published in the online journal BMJ Open.
 
The actual size of the health workforce in India is lower than the number of medical professionals registered with various councils and associations in the country. The research paper published in The BMJ Open by Dr Anup Karan, Additional Professor, Indian Institute of Public Health Delhi, (IIPHD) and his team came to this conclusion after comparing data from the National Sample Survey (NSS) and a review of published documents by the Central Bureau of Health Intelligence.
 
Despite the health sector employing five million workers in India it continues to have low density of health professionals with figures for the country being lower than those of Sri Lanka, China, Thailand, United Kingdom and Brazil, according to a World Health Organisation database. This workforce statistic has put the country into the “critical shortage of healthcare providers” category.
 
Bihar, Jharkhand, Uttar Pradesh and Rajasthan are the worst hit while Delhi, Kerala, Punjab and Gujarat compare favourably.
 
“Southeast Asia needs a 50% increase in healthcare manpower to achieve universal health coverage by 2030. India faces the problem of acute shortages and inequitable distributions of skilled health workers as have many other low- and middle-income countries,’’ said K. Srinath Reddy, president, Public Health Foundation of India.
 
Estimates of non-health workers engaged in the health sector and technically qualified health professionals who are not part of the current workforce is able to be provided in India for the first time by the study as it is based on data from two sources.
 
The authors retrieved data on the number of registered practitioners, such as doctors, nurses, physiotherapists and dentists, from published literature and websites of professional councils and organisations.
 
They also estimated the number of qualified and unqualified healthcare workers actually working in India using the 68th round (July 2011-June 2012) of National Sample Survey Organisation (NSSO) data on ‘Employment and Unemployment Situation in India’ – a household survey conducted every five years.
 
As well as registered practitioners, the health workforce in India includes many informal medical practitioners, such as traditional birth attendants, faith healers, snakebite curers, and bonesetters without formal education or training.
 
The total size of health workforce registered with different councils and associations was 5 million, but the NSSO estimated the size of the workforce to be 1.2 million fewer at 3.8 million.
 
Based on the registration data, the density of the total health workforce was estimated to be 38 per 10,000 population, but the NSSO data found it be lower at 29 per 10,000 population. In eastern and rural states total health workforce density was lower than the WHO minimum threshold of 22.8 per 10,000 population.
 
According to the registry data the density of doctors and nurses and midwives per 10,000 population across India was 26.7, whereas the NSS0 data put it at 20.6.
 
The estimates also reveal “an alarmingly large presence of unqualified health professionals,” as adjusting for adequate qualifications of health workers reduced the workforce density from 29 to 16 health workers per 10,000 population.
 
The presence of unqualified health professionals in the health system is not unique in India.
 
Unqualified health professionals are usually the first point of contact for rural and poor population in many low-income and middle-income countries.
 
Government medical colleges in the country produce 50 per cent of all doctors in India every year, but nearly 80 per cent of them work in the private sector.
 
The data also showed that approximately 25% of currently working health professionals do not have the required qualifications as laid down by professional councils, and that 20% of adequately qualified doctors are not in the current workforce. More than 80% of doctors and 70% of nurses and midwives were employed in the private sector.
 
Despite 71 per cent of the country being predominantly rural, the proportion of doctors and nurses in rural areas are 34 per cent and 33 per cent, respectively, it showed.
 
The density of health workers, including allopath and AYUSH doctors, nurses and midwives, in India is 20.6 per 10,000 population. Most central and eastern Indian states have a low density of health workers, ranging from approximately 23 per 10,000 population in Bihar and Northeastern states other than Assam, to as low as 7 per 10,000 population in Jharkhand.
 
The only South Indian state reflecting lower density than the all-India average is Andhra Pradesh (25), and the only eastern state having a higher density than the all-India average is West Bengal (36).
 
The highest concentration of health workers is in Delhi (67), followed by Kerala (66) and Punjab (52.)
 
Delhi has the highest density of doctors (34), but the density of nurse and midwife is the highest (38) in Kerala.
 
The researchers point to several limitations of their study, including the registration data being inadequately updated and likely to include deceased, unemployed and professionals who have migrated overseas, and the survey data being self- and also outdated reported.
 
Nevertheless the authors were able to conclude: “Distribution and qualification of health professionals are serious problems in India when compared with the overall size of health workers. The policy should focus on enhancing the quality of health workers and mainstreaming professionally qualified persons into the health workforce.”
 
The health workforce in India comprises broadly eight categories, namely: doctors (allopathic, alternative medicine); nursing and midwifery professionals; public health professionals (medical, non-medical); pharmacists; dentists; paramedical workers (allied health professionals); grass-root workers (frontline workers); and support staff.
 

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Image Courtesy: LiveMint

Indian has a shortage of an estimated 600,000 doctors and 2 million nurses, say the findings of a study by the Center for Disease Dynamic, Dynamics, Economic and Policy (CDDEP) in the US. This was reported by scientists who seemed to have found that the lack of proper training in administering antibiotics is preventing patients from accessing affordable life-saving drugs.
 
CDDEP produces “independent, multidisciplinary research to advance the health and wellbeing of human populations in the United States and around the world.”

Limited government spending for health services contribute to high medical costs for patients, reported the study by the CDDEP.

The health expenditure in India is largely out of pocket, as much as a staggering 65%, and such expenditures push more than 57 million people into poverty each year.

To identify key barriers in access to antibiotics in low and middle income countries, the researchers at CDDEP conducted stakeholder interviews in Uganda, India and Germany apart from literature reviews.

Gaps galore
There is a glaring gap in the international standards of health as defined by the World Health Organization (WHO) and as is practised in India. For example, though the WHO prescribes a doctor to patient ratio of 1:1000, in India, the study found that there is one doctor to every 10, 189 people. This implies a deficit of more than six lakh doctors. The nurse to patient ratio is 1:483 and has a glaring shortage of two million nurses!

Highlighting the accessibility or procurement of drugs as the primary challenge, Ramanan Laxminarayan, director at CDDEP said, “Lack of access to antibiotics kills more people currently than does antibiotic resistance, but we have not had a good handle on why these barriers are created.”

Recommendations of CDDEP study
The recommendations of the study say, “Interventions to improve access to antibiotics must take into account differences among countries. Healthcare institutions, both public and private, and regulatory, procurement, and supply chain systems need to meet users’ expectations and clinical best practices.”

It added that healthcare in many Low-Middle Income countries “requires fundamental changes, more government spending, and better regulation.” The study recommended that countries’ long-term visions should include plans to incorporate access to essential antibiotics into priority programs, such as infectious disease surveillance, HIV, Tuberculosis, malaria, and mother and child health programs, where efficient supply chains have already been established.

Emphasising the importance of National Health insurance schemes, it said, “National health insurance schemes can reduce out-of-pocket payments by patients, adequately fund health ministries, and dedicate funding for essential medicines, including antibiotics.”
“Ultimately, rising antibiotic resistance may be the biggest barrier of all. If resistance renders treatments ineffective, efforts to improve access to antibiotics will be futile, and the consequences will be felt worldwide. Antibiotic stewardship and infection prevention must therefore be pursued alongside improvements in access. All stakeholders—international bodies, government leaders, health and agriculture ministries, patients and medical practitioners, farmers and veterinarians, academia, and the pharmaceutical industry— must slow the emergence of resistance to existing antibiotics to ensure affordability and access everywhere,” the study concluded.

India’s spending
However, India’s public health expenditure is amongst the lowest in the world at 1.02% of its GDP in 2015 (a figure that has remained unchanged since 2009). This figure is lower than most low income countries.

The equivalent proportion of GDP spent on health in the Maldives is 9.4%, in Sri Lanka 1.6%, in Bhutan 2.5% and in Thailand 2.9% as per an IndiaSpend report.

Not surprisingly then, India has become the sixth biggest private spender on health among low-middle income countries. Out-of-pocket health expenditure pushed 55 million Indians into poverty in 2011-12.
 

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That health is not “merely the absence of disease or infirmity”, but “is a fundamental human right” was proclaimed 40 years ago in the Alma-Ata declaration in Kazakhstan in 1978. On October 25 and 26, 2018, the declaration was reiterated by 197 countries around the world as they signed the Declaration of Astana that vowed to strengthen primary healthcare as an essential step for achieving universal health coverage.

India, also a signatory to the Astana declaration, has to strengthen primary healthcare if it has to achieve health for all since it accounts for 17% global burden of maternal deaths, the highest number of tuberculosis cases and deaths in the world and the highest
number of stunted children in the world. As many as 55 million Indians slipped into poverty in 2011-12 because of health catastrophes they could not afford.
 

“[Astana declaration] is very important for not just India but the world as a whole to be reminded of the importance of primary healthcare as the foundation of a health system and as the critical component for achieving universal healthcare. It’s a timely reminder,” said K Sujatha Rao, former union secretary of health, public health expert and author of Do We Care: India’s Health System.

Shift from vertical programmes to holistic care
Even though the Alma Ata declaration called for global commitment to comprehensive primary health care in 1978, donor-driven programmes steered low and middle income countries towards ‘selective healthcare’ focussing on a few diseases and health needs, said K Srinath Reddy, president, Public Health Foundation of India, a think-tank and research institute.

Even the millennium development goals focussed on select targets and fragmented the health system into vertical disease programmes and segmented health services for specific diseases and age groups.

For example, 55% of the ministry of health and family welfare budget in 2018-19 was for the National Health Mission, of which maternal and child health component accounted for 74%. This despite the fact that non-communicable diseases such as hypertension, cancer and diabetes killed 61% Indians in 2016.

“The lessons of the past 40 years have taught us that vertical programmes, however nobly intended and well designed, cannot be force fitted in to a weak health system,” said Reddy.

India has taken steps to address the gap and included comprehensive primary healthcare in National Health Policy 2017.

An important component of the Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya Yojana (National Health Protection Scheme) is the health and wellness centres–sub-centres and primary health centres that will be converted to provide comprehensive care for communicable and non-communicable diseases.

“If implemented, this (health and wellness centres) can be a game changer,” said Rao. “I feel this should have been accorded high priority and sequenced to be achieved before launching the hospitalisation aspect of Ayushman Bharat.”

Health systems have to be built incrementally, and hospital insurance in India’s context is likely to be overwhelming and drain resources from primary healthcare, she added.

Improve quality of care and reduce barriers
Indian healthcare killed more people due to its poor quality than due to lack of access. In 2016,  1.6 million Indians died due to poor quality of care, almost double than those killed due to non-utilisation of health services (838,000), IndiaSpend reported in September 2018.

The current standard of sub-centres and primary health centres is poor and ill-equipped to take care of the needs of India’s growing population.

Sub-centres are at the forefront in providing healthcare at the local level; however 73% sub-centres were more than 3 km from the remotest village, 28% were not accessible by public transport and 17% were unhygienic, IndiaSpend reported in a two-part series (here & here) in  August 2018.

In 24 states, instances of non-availability of essential drugs were observed by an audit by Comptroller Auditor General (CAG). Further, there was a 24%-38% shortfall in the availability of medical personnel at primary health centres, sub centres, and community health centres in 28 states/union territories of India, CAG found.

This makes a large number of citizens–58% in rural areas and 68% in urban areas–to seek care from the private sector though it may not be any better in quality.

Implementing the Clinical Establishments (Registration and Regulation) Act (that is adopted by over 20 states) to set in standards and monitor the private sector may help in this aspect, Reddy had told IndiaSpend earlier. Also, having a composite health quality assessment system in place will bring in more transparency, he added.

Empowering and implementing Rogi Kalyan Samitis (patient welfare committees) that use community participation for improving facilities in public hospitals can also make a difference.

Pay and train frontline workers better, hire mid-level health workers
India’s over one million Accredited Social Health Activists (ASHAs), who are the frontline health workers, are inadequately trained and are underpaid.

About 70%-90% ASHAs said they needed better training, monetary support and timely replenishment of the drug kit to perform better. Only 22% ASHAs surveyed had some understanding of their role, IndiaSpend reported in May 2016.

ASHAs are now paid a honorarium of Rs 2,000 a month–equivalent to the cost of an up-market meal for two–up from Rs 1,000 from October 2018.

Poor living and working conditions, irregular drug supply, weak infrastructure, professional isolation and the burden of administrative work make working in rural areas difficult for doctors. This explains why there are 1,974 primary health centres without doctors and why 39% medical providers in PHCs in 19 major states were counted “absent”.

One alternative to meet the healthcare needs of rural population is training and employment of mid-level healthcare staff, also known as community health workers.

In one such initiative, in Chhattisgarh, rural medical assistants (RMAs), a special cadre of health providers trained for three-and-a-half years, were inducted into the state’s health workforce to fill the gaps created by vacancies for medical officers in PHCs.

It was found that RMAs performed the best in terms of prescribing drugs, and the perceived quality scores were the highest for RMAs (85%), followed by medical officers (84%), AYUSH medical officers (80%) and paramedicals (73%), IndiaSpend reported in October 2018.

“We need to increase the numbers, skills, salaries and social status of community health workers, auxiliary nurse midwives, nurse practitioners and community health officers trained in a three-year programme,” said Reddy.

“We should equip and train them in easy-to-use technologies adapted to point of care diagnostics, decision support systems and tele-consultation,” he added. “They should become part of village and block level health planning and monitoring process and be enabled to become the trusted community connects of the health system.”.

Spend more on health
India spent 1.02% of its gross domestic product (GDP) in 2015–a figure that remained almost unchanged in six years since 2009. Also, India’s public health expenditure is amongst the lowest in the world, lower than most low-income countries which spend 1.4% of their GDP on health, IndiaSpend reported in June 2018.

The money India spends on public health per capita every year is Rs 1,112, less than the cost of a single consultation at the country’s top private hospitals or roughly the cost of a pizza at many hotels and about Rs 93 per month or Rs 3 per day.

This increases the share of out-of-pocket (OOP) expenses for Indians, and have made Indians the sixth biggest OOP health spenders in the low-middle income group of 50 nations.

The National Health Policy 2017 talked about increasing public health spending to 2.5% of GDP by 2025, but India hasn’t yet met the 2010 target of spending 2% of GDP.

Despite greater investment in health with Ayushman Bharat Scheme, it may not necessarily lead to greater improvement in primary care if stacked against expensive hospital insurance model, said Rao. “India has never spent more than 1.2% of GDP for health,” Rao said. “Primary healthcare alone needs 1% of GDP to bring it up to some standards. So unless there is a significant increase in health budgets, choices will always favour hospital insurance.”

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend
 

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These calculations by the Public Health Foundation of India (PHFI), an advocacy, were released on June 6, 2018, and based on the official Indian standard for poverty line–a monthly expenditure of Rs 816 in rural areas and Rs 1,000 in urban areas–as per a 2013 report of the erstwhile Planning Commission. The PHFI study used secondary data from National Sample Survey reports and other sources for these estimates.
 
Over 80% of Indians incur OOP–direct payments individuals make to healthcare providers–on healthcare, as per 2011-12 figures cited in the study. It was 60% in 1993-1994. Medicines contributed to more than 67% of OOP healthcare expenditure in 2011-12.
 
In real terms, monthly OOP payments increased by more than 100%–from Rs 26 in 1993-1994 to Rs 54 in 2011-2012.
 
India spends the least on public health among BRICS nations, IndiaSpend reported on May 18, 2017. It ranked 147 among 184 countries, a notch below Pakistan, in this regard. Insurance-based government initiatives have been largely unsuccessful in easing the burden on citizens, the report added.
 
The heavy load of spending on medicines can be explained by a study carried out in Chhattisgarh reported by IndiaSpend on June 13, 2018. An analysis of 1,290 prescriptions from 100 public health facilities across 15 districts showed that only 58% prescribed medicines were available at government pharmacies. This left patients with no option but to buy at higher rates from private pharmacies.
 
The consequence of the inadequate public health system is that India has become the sixth biggest private spender on health among low-middle income nations.
 
About 68% of the Indian population has limited or no access to essential medicines, according to a World Health Organization report. In addition, over the last two decades, the availability of free medicines in public health facilities declined from 31.2% to 8.9% for inpatient care and from 17.8% to 5.9% for outpatient care, according to a 2011 PHFI study.
 

Source: Public Health Foundation of India Study 2018
 
Cancer treatment cost highest
The PHFI study also looked at the disease conditions which contributed the most to the financial burden on households.
 
It found that the treatment of cancers, cardiovascular diseases and injuries–in terms of both outpatient and inpatient care–dominated health expenditures in India. The share of non-communicable diseases–such as cardiovascular problems, diabetes, cancer, mental illness and injuries–in OOP health expenses increased from 31.6% in 1995-1996 to 47.3% in 2004.
 
The survey results suggested that the most common health condition for seeking outpatient care was fever (22.7%) and for inpatient care was childbirth (27.3%).
 
In addition, the study estimated that households incurred the highest monthly OOP spending on cancer (Rs 5,121), in the case of both outpatient and in-patient care. This is followed by injuries in outpatient care (Rs 3,045) and cardiovascular events in inpatient care (Rs 2,808).
 
Two earlier studies–the PLOS study of 2013, and the World Bank study of 2014–too had reported that households incurred significant OOP payment burden in the case of cardiovascular diseases and cancers.
 
Rise in poverty caused by health expenses in 2011-12

The study calculated the implications of OOP and the part of it spent on medicines for poverty estimates by using three steps:

 
As per these calculations, monthly OOP payments and expenditure on medicines deepened poverty among the poor by Rs 29 and Rs 23, respectively, in 2011-2012. And the percentage of households below the poverty line increased from 4.19% in 1993-1994 to 4.48% in 2011-2012.
 
This rise in poverty was sharper in 2012 than in 2004-2005 and 1993-1994. The headcount ratio of those impoverished due to OOP payments was 3.97% during 1993–1994; this inched up to 4.30% in 2004-2005 and then went up in 2011-2012 to 4.04%, as per the global measure for poverty line ($1 per day).
 
There was an increase of more than 50% in every household’s consumption expenditure in real terms over this period–from Rs 517 to Rs 794.
 
(Salve is an analyst with IndiaSpend.)

Courtesy: India Spend
 

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At 1.02% of its gross domestic product (GDP)–a figure which remained almost unchanged in nine years since 2009–India’s public health expenditure is amongst the lowest in the world, lower than most low-income countries which spend 1.4% of their GDP on health, according to the National Health Profile, 2018, released by union minister for health and family welfare, J P Nadda, on June 19, 2018.
 
Sri Lanka spends about four times as much as India per capita on health, and Indonesia more than twice. India spends 1.02% of gross domestic product (GDP) on public health, compared to 1.4% by low-income countries, the new data reveal.
 
The equivalent proportion of GDP spent on health in the Maldives is 9.4%, in Sri Lanka 1.6%, in Bhutan 2.5% and in Thailand 2.9%.
 
The National Health Profile covers information on demographic, socio-economic, health status and health finance indicators, and on health infrastructure and human resources.
 
The National Health Policy 2017 talked about increasing public-health spending to 2.5% of GDP by 2025, but India hasn’t yet met the 2010 target of 2% of GDP, IndiaSpend reported in April 2017.

 
Source: National Health Profile, 2018
 
India’s low public-health spending is one reason why patients turn to the private sector for healthcare. Indians are the sixth biggest out-of-pocket (OOP) health spenders in the low-middle income group of 50 nations, we reported in May 2017. These costs push around 32-39 million Indians below the poverty line every year, according to various studies.
 
Without a significant increase in its healthcare budget, India’s health targets seem difficult to achieve: Reducing the infant mortality rate from 41 deaths per 1,000 live births in 2015-16 to 28 by 2019 and maternal mortality ratio from 167 deaths per 100,000 births in 2013-14 to 100 by 2018-2020, and eliminating tuberculosis by 2025.
 
India’s $16 (Rs 1112) per capita spend on health is fourth lowest in the South East Asian Region.
 

Public Expenditure On Health, South East Asia

Source: National Health Profile, 2018
 
“If you don’t increase public financing, you get into the mindset that the public sector cannot do anything,” Srinath Reddy, president of Public Health Foundation of India, an advocacy, told IndiaSpend in January 2018. “You have to leave it to the private sector to do what it wants and lose the opportunity to create a system that provides accessible and affordable care, which is the essence of universal health coverage.”
 
Which state is the best and the worst?
 
In order to evaluate the health performance of states by health spending, IndiaSpend compared the 2017-18 health index of NITI Aayog, the government’s think tank, with the per capita spending of Indian states on health.  
 
The NITI Aayog’s health index measures a variety of health outcomes, including infant and under-five mortality rate, sex ratio at birth, immunisation coverage, institutional deliveries and health monitoring and governance indicators, such as occupancy of hospital beds, and processes, including infrastructure and human resources.
 
Mizoram’s per capita health expenditure is Rs 5,862, almost five times the Indian average, with the state spending 4.2% of its GDP on health in 2015. Arunachal Pradesh (Rs 5,177) and Sikkim (Rs 5,126) followed at the top.
 
At the other end of the spectrum, Bihar spent Rs 491 per capita on health, less than half the Indian average, spending 1.33% of its GDP on health. Just above Bihar were Madhya Pradesh (Rs 716) and Uttar Pradesh (Rs 733).
 
Mizoram ranks second on the NITI Aayog’s health index, while Bihar ranks fourth from the bottom.
 
However, health spending alone cannot improve a state’s health performance.
 
Nagaland, which spent Rs 2,450 on health per capita, ranked third from the bottom on the health index, while Kerala, which spent Rs 1,463, ranked first on the health index.
 

Source: Niti Aayog, National Health Profile, 2018
 
(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend
 

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Hypertension was also the fourth-leading risk factor for death and disability and responsible for over 1.6 million deaths in India—more than the population of Mauritius and double the population of Bhutan–in 2016, according to the Global Burden of Disease data collated by the Washington-based Institute for Health Metrics and Evaluation.
 
Malnutrition, air pollution, risks from a diet low in fruit, vegetables and whole grains, but high in salt and fat–these are the three top risk factors of death and disability in India, as IndiaSpend reported in November 2017.
 
High blood pressure is easy to prevent, diagnose and treat, but most Indians are unaware of the problem and even fewer have it under control, said experts.
 
A chronic condition when the blood pressure of the blood vessels remains raised, hypertension is often called a silent killer because it comes without symptoms. Consistent high blood pressure affects major organs such as brain, heart and kidneys and is a major cause of premature deaths, leading to 9.4 million deaths globally in 2013.
 
Hypertension was responsible for 53.8% of all deaths due to heart disease, 55.7% of deaths due to stroke, and 54.3% of deaths due to chronic kidney disease in India in 2016, data show.

 
 
“Hypertension or raised blood pressure is one of the leading causes of premature deaths in India. It is directly responsible for 29% of all stroke and 24% of heart attacks in India,” said Balram Bhargava, director general, Indian Council of Medical Research (ICMR) at the May Measurement Month 2018. This is part of the annual awareness campaign held by the London-based International Society of Hypertension.
 
Only 10% rural, 20% urban Indians have BP under control
 
Non communicable diseases such as heart disease, diabetes, chronic respiratory diseases, cancer and others cause 60% of deaths in India, 55% of them prematurely. India stands to lose $4.5 trillion (Rs 311 lakh crore) between 2012 and 2030 on this count, due to these diseases, according to the nonprofit World Economic Forum, as IndiaSpend reported in October 2017. This loss is one-and-a-half times India’s 2018 gross domestic product (GDP) of $2.8 trillion (Rs 187 lakh crore) as on April 1, 2018.
 
It is estimated that 29.8% of Indians have hypertension, with 33% prevalence in urban and 25% in rural India. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. Only 25% rural and 38% of urban Indians are being treated for hypertension. Further, only 10% of rural and 20% of urban Indian hypertensive population has its BP under control, according to a 2014 review published in the Journal of Hypertension.
 
“In rural areas, some studies have showed that 10% of them are aware of their hypertension and only 7% of them are able to control it,” said Dorairaj Prabhakaran, vice president, Public Health Foundation of India (PHFI) and executive director, Centre for Chronic Disease Control, at the event.
 
He quoted an eight-country comparison where India was at the bottom–only 24% in India were aware of hypertension, 20% of them were treated and only 6-10% had it under control.

 
 
Continued treatment, diet: Why few manage to control high BP
 
Hypertension can be treated with common inexpensive drugs, yet the compliance is a problem.
 
“Often patients themselves decide to stop the hypertension drugs thinking they are cured which can be dangerous,” said C Venktata S Ram, director, World Hypertension League and editor-in-chief, Hypertension Journal.
 
The experts stressed the importance of lifestyle modification in preventing and controlling hypertension.
 
Reducing salt, avoiding alcohol and tobacco consumption, controlling body weight, getting regular exercise, eating more fruits and vegetables–these diet and lifestyle changes can bring down hypertension. Avoidance of processed foods such as jam, ketchup and salty snacks like chivda is also recommended.
 
“Keep away from APC,” said Bhargava referring to achaar (pickle), papad and chutneys, three staples in Indian meals.
 
An average Indian consumes 10.98 grams of salt per day–119% more than the recommended limit of five grams per day by the World Health Organization–IndiaSpend reported in November 2016.
 
‘Need to screen 1 million Indians above 18 years of age’
 
Since hypertension does not cause symptoms, periodic screening for all adults is the only way to detect it early. The goal is to screen about 1 million Indians above the age of 18 who haven’t been screened yet, said Prabhakaran.
 
Government will be screening communities through renewed attention being paid to non-communicable diseases (NCDs) with schemes like the National Health Protection Mission.
 
“There are already 2500 NCD clinics which have screened 2.25 crore (22.5 million) people till now and 12% have been found to suffer from hypertension,” said Manas Pratim Roy, deputy assistant director general, Directorate General of Health Services.
 
(Yadavar is a principal correspondent with IndiaSpend.)
 

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What can MHWs do in rural areas? Gender inequities in developing societies mean that men play a dominant, decision-making role in reproductive health. MHWs can make a difference by educating men about maternal health issues and guiding their decisions, said the study. They can also complement the efforts of female health workers in delivering health services in remote areas and at late hours.
 
However, this may prove to be difficult in India. There are no MHWs in 48% of health sub-centres in Indian villages; and overall, there is a 65% shortage of MHWs in public health centres, according to the Rural Health Statistics 2016.
 

Source: Rural Health Statistics 2016
 
It is clear India has to improve its maternal-health services. The government scheme to reduce maternal mortality rate, Janani Suraksha Yojana (JSY), has helped push up institutional deliveries by 15% over the decade ending 2014, according to this 2016 report by Brookings India, a think tank. But as IndiaSpend reported in February 2017, JSY is often not delivering quality care to the country’s poorest women.
 
This lack of access could explain why India accounted for close to a fifth of 303,000 maternal deaths and 26% of the neonatal deaths globally, as IndiaSpend reported in September 2016. MHWs can help improve the coverage of maternal and newborn child health services delivered by the formal health care system, and improve home-based management of these services.
 
To research the role MHWs could play, the study recruited and trained men to complement the work of female health workers. An IndiaSpend analysis of the findings of the study and other data reveals three reasons why MHWs were effective in improving the quality of maternal and newborn child health services:
 
1. Female health workers struggle with mobility, security issues
 
In rural India, sub-centres are the ‘first port of call’ for accessing health care. Ideally, sub-centres in remote and hilly areas should be manned by at least two auxiliary nurse midwives (ANMs), one male multipurpose worker, one pharmacist and one AYUSH doctor or community health officer. There was an increase of 5% in sub-centres from 2005-15, IndiaSpend reported in February 2016.
 
Each ANM is assisted by four to five Accredited Social Health Activist (ASHA) workers who are responsible for delivering health services to the village population but they face some obvious challenges at work given prevailing gender norms.
 

• Night deliveries: The study interviewed women who spoke about the risks associated with night deliveries when villages are far from health facilities and there is a lack of ready transportation. In such cases, female health workers (FHWs) are often unable to help pregnant women reach a hospital. MHWs, on the other hand, can facilitate pregnant women’s access to health services, especially during night, as observed during the study.
• Communication gap with husbands: The reach of FHWs to men in local communities is limited due to gendered norms and other factors, according to the study. MHWs can bridge the communication gap with husbands and educate them about various aspects of reproductive health.

An estimated 22% of sub-centres are short of ANMs and in 30% of India’s districts, sub-centres with ANMs serve double the patients they are meant to, IndiaSpend reported in September 2016. MHWs can help the system deal with these shortages.
 
2. MHWs can convince men about the need for better maternal care
 
The subordinate position of women in Indian society has been acknowledged as a fundamental constraint to women’s access to reproductive health services. Women tend to have less access to household resources.
 
Nearly 80% of women in India said they had to seek permission from a family member to visit a health centre. Of these, 80% said they needed permission from their husbands, 79.89% from a senior male family member, and 79.94% from a senior female family member, according to the 2012 Indian Human Development Survey (IHDS) survey, IndiaSpend reported in February 2017.
 
However, regional variations exist. As many as 94% of women reported needing permission to visit a health centre in Jharkhand, the highest in any state, while only 4.76% of women in Mizoram said they needed to ask family members, the lowest.
 
Given this social structure, MHWs can convince husbands–who have poor knowledge on the do’s and don’ts during pregnancy, childbirth and the postpartum period–about the importance of providing antenatal care and health services during pregnancies.
 
India’s RMNCH+A (Reproductive, Maternal, Newborn, Child and Adolescent) health strategy–formulated in 2013–recognised the central role of men in women’s reproductive health and includes guidelines for training of health workers to provide husbands of pregnant women with the relevant information.
 
Interventions to promote the involvement of men during pregnancy, childbirth and after birth have been strongly recommended by the World Health Organization in its 2015 report on recommendations on health promotion interventions for maternal and newborn health.
 
3. Complementing the work of female health workers
 
Coverage of maternal health services in west Odisha’s Keonjhar district, where the study was focussed, improved due to increased MHW engagement. The male health workers arranged transport and accompanied pregnant women to distant health facilities in emergencies and, according to the ASHA workers interviewed in the study, also sometimes climbed hills to reach distressed households in different settlements.
 
At the time of deliveries, the gendered division of labour was apparent, researchers found. MHWs handled tasks outside of the delivery room–keeping track of the family’s personal items, obtaining medicines, and in cases where a blood transfusion was necessary, obtaining donated blood.
 
One ASHA worker who was interviewed during the study said: “He [MHA] cannot enter in the delivery room. He brings the medicine which is required and all things he [the health professional] tells; he [MHA] tells the husbands (sic). I can convince the mothers but not the husbands.”
 
Male health workers have made a difference in other developing nations
 
Health initiatives that are shouldered by both male and female health workers have worked well in other countries. There is a significant need to scale up men’s participation in maternal health and provide them with the sufficient information to help them make decisions and support their partner’s decisions concerning family health, wrote Olena Ivanova, a maternal health expert at the International Centre for Reproductive Health, Belgium, in this blog in February 2015.
 
“More rigorous evaluations of male involvement initiatives, attention to vulnerable and disadvantaged families, acknowledgement of heterogeneity of fathers’ groups, revision of policies and laws and closer collaboration between different sectors are needed in order to strive for better maternal and newborn health outcomes and well-being,” she added.
 
Evidence from Rwanda, among the few countries to pair male and female health workers, indicates that the approach could work in settings where it is not safe or socially acceptable for women to travel alone. And educating pregnant women and their male partners leads to better maternal health behaviour than educating women alone, according to this 2006 study in urban Nepal.
 
However, it is important to tread cautiously, said the study.
 
To reinforce these successes, as the study showed, MHWs should operate in ways that do not contribute to widening gender inequalities in favour of men.
 
(Saha is an MA Gender and Development student at Institute of Development Studies, University of Sussex.)

Courtesy: India Spend
 

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