HEALTH AND NUTRITION

SCOPE

Drug Pricing and Pharmaceutical Policy

C P Singh
l Control

HE DEPARTMENT of Pharmaceuticals was established on 1 st July 2008 as the nodal Department for ensuring the availability of medicines at reasonable prices in the country. Availability of good quality drugs at affordable prices with a speciic focus on the poor has been the constant endeavour of the Government. The Government is administering Drug Price Control through the Drug Price Control Orders issued from time to time.

of price of any nonscheduled formulation in public interest.

Within healthcare, the cost of medicine is the major cost driver which constitutes nearly 60-70 percent of the total healthcare cost

Under Drug Policy 1994, DPCO 1995 was framed with the following salient features:l 74 Bulk Drugs and their formulations under price control
l l

Cost based pricing of bulk drugs Pr icing of indigen ous ly manufactured scheduled formulations under speciied formula i.e Cost + MAPE (Maximum Allowable PostManufacturing Expenses) not exceeding- 100 percent For imported formulations : Landed Cost plus margin not exceeding 50 percent

The Drugs (Price Control) Order, 1995 (DPCO,95) was promulgated by the Government of India on 6th January, 1995 in exercise of the powers conferred by Section 3 of the Essential Commodities Act. Under DPCO,95, seventy six bulk drugs (subsequently reduced to 74) are included in its First Schedule. These bulk drugs are scheduled bulk drugs. The Government of India is empowered to fix and notify the price of scheduled bulk drugs and their related formulations. NPPA has been effectively performing its role of a regulator of the prices of speciied drugs. The National Pharmaceutical Pricing Authority (NPPA), an independent body of experts in the Ministry of Chemicals & Fertilizers was formed by the Government of India. The functions of NPPA, interalia, relates to ixation/revision of prices of scheduled bulk drugs/ formulations under DPCO1995 monitoring and enforcement of the prices.

The author is Chairman, National Pharmaceutical Pricing Authority (NPPA). 10 YOJANA October 2012

The Authority has been entrusted with the task of price fixation/ revision and other related matters such as updating the list of drugs under price control by inclusion and exclusion on the basis of the established criteria/ guidelines. The Authority is empowered to take inal decisions, which is subjected to review by the Central Government as and when considered necessary. The Authority is also required to monitor the prices of decontrolled drugs and formulation and oversee the implementation of the provisions of the Drugs (Price Control) Order. NPPA also monitors the availability of drugs throughout the country and take corrective action if any shortage of medicines is noticed. An overview of the Indian Pharma Industry is given hereunder: NPPA while implementing DPCO,95 undertakes Pricing (Price Fixation, Review of Prices, Intervention, Check & Correction, Enforcement), Overcharging (Detect, Demand, Deposit), Monitoring (Monitor Prices, Monitor Availability, Market-Surveillance, MarketIntervention, Maintain Price Line) of Pharmaceutical Drugs. The progress made in this regard is stated below: Monitoring of Non Scheduled Formulations With a view to keep a close watch on price changes, monitoring mechanism is in place. The monitoring of prices of nonscheduled formulations is currently done on the basis of data from IMS Health. The ceiling for annual price increase has been reduced to 10 percent from 20 percent since 01.04.2007.
YOJANA October 2012

Bulk Drug Units Formulation Units Total Pharma Units No. of bulk drugs produced in the country No. of formulation packs Produced Total Turnover (i) Domestic (ii) Exports Global Position of Indian Pharma Average Growth of domestic market during 2006-07 to 2009-10

2389 8174 10563 >600 >61325 Rs.1,04,209 Crs. : 2009-2010 Rs.62,055 Crs. : 2009-2010 Rs.42,154 Crs. : 2009-2010 3rd in Volume & 14th in Value 11.6 percent

Price Fixation/Revision Progress upto Aug., 2012 Bulk Drugs

Particular 200910 201011 201112 2012-13 (upto 31st Aug., 12) Since inception of NPPA (till 31st Aug., 2012 153 346 17 10 526

Price Increased Price Decreased Price ixed for First Time No change In Price Total

15 10 02 01 28

10 07 01 03 21

19 01 0 1 21

1 03 0 0 04

Formulations (Number of Packs)

Particulars 2009-10 201011 201112 2011-12 (upto 31st Aug., 2012) 72 83 165 32 352 Since Inception of NPPA (till 31st Aug., 2012) 1861 3492 6227 432 12012
11

Price Increased Price Decreased Price ixed for irst time No change in prices Total

184 450 1155 35 1824

223 60 371 59 713

257 50 239 61 607

Action and Price ixation under para 10(b) of DPCO,1995 Prices of 30 non-scheduled medicines have been ixed under para 10(b) till August, 2012, the details of which are available on NPPAs website. As a result of action under this provision, 33 manufacturers have voluntarily reduced prices of 65 packs and prices of 30 packs has been fixed by NPPA. In this way prices of 95 nonscheduled packs have been reduced so far. Availability of Drugs NPPA monitors the availability of drugs and identiies shortage, if any, to take remedial steps to make the drugs available. NPPA is carrying out this responsibility mainly through monthly field reports from the State Drugs Controllers and other available information. As and when the reports of shortage of particular drug(s), in any part of the country are received, the concerned company is asked to rush the stocks and to make the drugs available. Generally, shortages

reported are brand speciic where alternate brands are available. Enforcement of provisions of DPCO, 1995. A separate enforcement division was created during the Year 2007-08 to facilitate detection of violation of DPCO 1995 with the following objectives: Market Surveillance of prices of scheduled drugs (i) Purchase of samples by NPPA oficers all over India to ensure compliance; (ii) E x a m i n e c o m p l a i n t s b y individuals / NGOs/VIP references. Based on an analysis, specific cases are identiied for (i) Recovery of overcharged amounts; (ii) Fixation of prices, where ever required. Status of overcharging cases Demand notices for overcharging have been issued from inception of NPPA. India has some of the poorest Price Change - Number of Packs

health indicators in the world and highest disease burden. This makes all the more important that the medicines need special priority from Government, Trade Associations, Industry and Consumer Organizations. Within healthcare, the cost of medicine is the major cost driver which constitutes nearly 60-70 percent of the total healthcare cost. 80- 90 percent of healthcare in India is out of pocket without intermediation and risk buffer of health insurance. The scenario underscores the criticality of containing drug costs for affordable healthcare. India is recognised world wide as a low cost producer of quality drugs. Indian Pharma Industry is making all out efforts to ensure availability of medicines and taking India to a leadership position in Global Pharmaceutical Arena. Government is taking all necessary steps in supporting the Indian Pharma Industry by ensuring adequate availability of highly skilled and trained manpower, rationalising taxes, providing various fiscal and non-fiscal

Sl. No. 1. 2. 3.

Price Change Jan Increase Percentage Decrease Percentage No Change Percentage Total 181 (0.3 percent) 92 (0.15 percent) 60762 (99.55 percent) 61035 (100 percent)

2011 Feb Mar Jan

2012 Feb 20 (0.03 percent) 11 (0.02 percent) 61294 (99.95 percent) 61325 (100 percent) Mar 62 (0.10 percent) 16 (0.03 percent) 60884 (99.87 percent) 60962 (100 percent)

07 1146 04 (0.01 percent) (1.89 percent) (0.007 percent) 05 374 02 (0.01 percent) (0.62 percent) (0.003 percent) 60610 (99.98 percent) 58978 (97.49 percent) 61246 (99.99 percent) 61252 (100 percent)

60622 60498 (100 percent) (100 percent)

12

YOJANA October 2012

Achievements
Year No. of Samples Collected 1450 520 464 553 559 230 Prima Facie Violations detected 840 284 246 225 156 41 Referred for Overcharging 456 172 208 216 152 39 Identiied for Price ixation Para 8 (6) violation 384 112 38 9 4 2

2007-08 2008-09 2009-2010 2010-2011 2011-2012 2012-2013 (upto August, 2012)*

* 35 cases are under process

The details of demand and recovery etc. till 31st August, 2012 is as follows:Particulars Number of Cases 857 113 744 Demand Notice issued (Rs. in Crores) 2574.08 2429.17 144.91 Amount recovered (Rs. in Crores) 234.62 180.60 54.02 Pending Recovery (Rs. in Crores) 2339.46 2248.57 90.89

Total Cases Under Litigation Other Cases

incentives for R & D and minimal price control. NPPA with the assigned mandate endeavours to maintain a balance in the conlicting interests of the consumers and producers. An effort is made to make the consumers vigilant of his rights in respect of quality of the medicines and prices charged overtime. At the same time while fixing the prices of Bulk

Drugs/ Formulations it is ensured that justice is being done with all rationality and objectivity in its approach. Information system relating to how medicine prices change in a country reported by a national medicine price monitoring system can be a valuable tool for governments, policy makers, health professionals, civil society

and other interested local or international parties for decision making, evaluation and advocacy purposes. NPPA has increased its focus on the monitoring of prices more and has made appropriate interventions. While significant ground has been traversed, much more endeavours to be covered within the mandate of DPCO, q 1995.

Everything you want to know about nutrition

The Union Ministry of Women & Child Developments recently launched a website on Nutrition. This interactive website will offer a knowledge bank, library and e-forum to those in the business of nutrition and the ones interested in eating right to stay healthy. Currently there is just too much information about food, nutrition and various types of diets. There are various experts in the ield of food and nutrition who give out information which at times can be contradictory and even confusing for the public. Besides working at bridging the gap of clarity on nutrition and its co-relation with health, the website will also give a birds-eye view of what the national and international community has to say on a particular diet or issue. The site is also meant for policy-makers. The website will help the policy-makers to connect with and understand the publics nutrition concerns. Besides being of public use, the website is also expected to help the Government with real-time monitoring of the Integrated Child Development Services.

YOJANA October 2012

13

HEALTH AND NUTRITION

PERSPECTIVE

Indias Health-Issues and Challenges

Shailaja Chandra

Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention

HE CHALLENGES facing Indias health sector are mammoth. They will only multiply in the years ahead. Surprisingly many of the challenges are neither a result of the paucity of resources nor of technical capacity. These hurdles exist because of a perception that the possible solutions may find disfavour with voters or inluential power groups.

of rewards and punishments. Divergent Attitudes to Birth Control. In the aftermath of the 1975 Emergency and the odium of forced sterilisations, the emphasis on population control shrivelled in most of North India. While countries like Korea and Iran which then had fertility rates far higher than ours, embraced the joys of planned parenthood, India dodged the subject. In 1994 the country adopted a target free policy and the states were encouraged to implement a cafeteria approach while supplying contraceptives. However the southern states of Kerala and Tamil Nadu unlike the rest of the country went full force to make family planning their topmost priority. No matter which party came to power, political support was there in abundance. In the mid- eighties the programme was spearheaded by no less than the state Chief Secretary of Tamil Nadu, Mr. T V Anthony, (nicknamed Tubectomy-Vasectomy Anthony) which speaks for itself. With enthusiastic politicians, civil servants and doctors joining hands, Kerala and Tamil Nadu reduced fertility rates to equalise European

The first malady has been the utter neglect of population stabilisation in states where it matters the most. The second is the monopoly that an elitist medical hierarchy has exercised for over 60 years on health manpower planning. The result has given a system where high-tech speciality services are valued and remunerated far higher than the delivery of public health services. The latter ironically touches the lives of millions. Related to this is the third big challenge -- how to make sure that doctors serve the growing needs of the public sector when the working conditions are rotten, plagued by overcrowding, meagre infrastructure and a virtual absence

The author was Secretary in the Ministry of Health & Family Welfare, Government of India and former Chief Secretary, Delhi. 4 YOJANA October 2012

levels. That was more than 20 years ago. Meanwhile, North India (where most of the emergency driven sterilisations had taken place) recoiled from the very mention of family planning- a mind-set that persists even to this day. The Challenge of Reducing Maternal and Infant Mortality There is a clear correlation between the health of the mother and maternal and infant mortality. In the northern states more than 60 percent of the girls and boys (respectively) are married well before the legal ages of 18 and 21. The repercussions of early pregnancy and child birth have not even dawned on the pair when they wed. The irst child arrives within the year when most adolescent girls are malnourished, anaemic and poorly educated. With no planned spacing between the births, another

child is born before the young mother has rebuilt her strength or given sufficient nutrition and mothercare to the irst born. These are among the main causes of high deaths of young women and infants. The chart and tables clearly show the regional difference in maternal, infant and child mortality. Narrowing the gaps poses one of the biggest health challenges. The regional variations in the deaths of mothers in the states of Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, Chattisgarh, Odisha, Rajasthan and Assam show that the percentage of maternal deaths is 6 times higher than in the Southern states. Taken together the EAG States and Assam account for 62 percent of the maternal deaths. Schemes for nutrition, supplementary feeding, literacy, the right to education

and health care remain hollow expressions without any meaning as long as women (and chiely adolescents) have no control over pregnancy. Unlike other South and South East Asian countries the use of IUD and injectibles has not taken off in India -nor are these the thrust areas for family planning anywhere in the country. Although long term, reversible methods of preventing pregnancy are available, young mothers and children continue to suffer or die. The challenge lies in bringing the issue to centre stage and not wait for incremental improvements to take place in the fullness of time. The charts show the colossal difference that has been achieved by the southern states that invested heavily in family planning (albeit through the adoption of terminal methods like sterilisation which can be avoided today). Health Management and Manpower Planning The second challenge relates to a obsession for exclusivity that has consumed the medical sector for too long. The Councils that regulate education and register the practitioners (Medical Council of India (MCI), Dental Council, Pharmacy Council, Nursing Council) were established with laudable goals- to elect a cross section of doctors and other health professionals democratically and to entrust to them the responsibility for designing and executing professional corses. It was expected that the countrys needs for professional health manpower would be met both qualitatively and quantitatively. But because the Councils were constituted through a political process of elections, the baggage of money, patronage and quid pro quos became a predictable
5

Regional Variations: Maternal Mortality Ratio* (MMR)

Extract from-Special Bulletin (June, 2011) on Maternal Mortality in India 2007-09 (Sample Registration System) Ofice of Registrar General, India *MMR: Maternal deaths per 1,00,000 live births

YOJANA October 2012

Table 1 : Levels of MMR by Regions 2007-09 Region EAG* states & Assam Southern states Other states India MMR 308 127 149 212 % to Total Maternal Dealths 61.6 11.4 27.0 100.0

In the Industrial countries the average MMR (adjusted 2008) is i4 EAG* (Empowered Action Group) states are Bihar, Jharkhand, Chhattisgarh, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and Uttarakhand Source: Special Bulletin on Maternal Mortality in India 2007-09 (SRS, 2011) Ofice of Registrar General, India and Unicef SOWC, 2011

accessory. Today, gaining entry to professional colleges has become highly commercialised-ultimately reflecting in the aspirations of the health fraternity to reap back benefits from huge investments incurred. As the quest to produce specialists and super specialists grows, the production of qualiied technical manpower has declined severely creating a mis-match which cannot be corrected by people who work in silos and lack the understanding and vision to think of the countrys health needs in totality. The Challenge of Establishing NCHRH The neglect of public health is one of the fallouts of the elitism that

has pervaded medical education. Whereas cities and towns at least have alternatives available- at a price- epidemics and acute illnesses that occur in rural areas often leave people in the hands of fate. The erstwhile elected MCI had relegated public health to the lowest rung of the health hierarchy and the doctors that once decimated dreaded diseases like malaria and smallpox are not to be found. The complement of technical staff, nurses, pharmacists, dentists, lab technicians and operation theatre staff are all in short supply outside the urban areas as the bodies that register them do not work in tandem. More importantly no Council has a stake in health care of any particular state- leave alone the country.

The proposal to set up a National Council for Human Resources in Health (NCHRH), far from being a bureaucratic response was a well thought out strategy having its roots in the recommendations of independent think tanks and expert committees. The rationale for setting up such an umbrella body was to see that the goals of health manpower planning, the prescription of standards, the establishment of accreditation mechanisms and preservation of ethical standards were served in a co-ordinated way, on the lines of structures that operate successfully in other countries. The Indian Medical Association in particular and doctors in general have been arguing against the need for such a body because they perceive it as a threat to their autonomy and a camouflage for political and bureaucratic meddling. The fact that health manpower planning was simply ignored, that there was a complete lack of coordination between the councils and most important of all the fact that public health had become a low priority have been overlooked in the fire and fury of opposing the NCHRH concept tooth and nail. The challenge today is how to ensure that the health sector produces adequate professionals as required for the primary, secondary and tertiary sectors, both for the public as well as the private sector health facilities. If the NCHRH Bill before the Standing Committee of Parliament does not see light of day, the resurrection of the superseded scam-ridden MCI is a foregone conclusion. The Challenge of Allopathy and AYUSH. Public health cannot be run on contract basis and much less be

YOJANA October 2012

The Challenge of Retaining Doctors The most important concern by far is to decide what kind of medical and public health cover is necessary and feasible to be given to people living beyond the bigger towns and cities. If all general duty doctors are making a beeline for post graduation- failing which opting for management, administration and even banking jobs (because cities are better places to live in,) the facts must be faced. Pursuing post-graduation, migrating abroad and prospecting for jobs outside the medical sector cannot be stopped by any Government. But ixed term requirements to stay bonded to the public sector can certainly be insisted upon for state sponsored medical graduates. But equally the working conditions, facilities and remuneration of such doctors should be respectable. In the state of Jammu & Kashmir the compensation given for working in more dificult areas has been graded. Such practical solutions can greatly bolster doctor retention. At the end of the day, the challenges of the health sector can only be met if doctors, essential drugs and supporting staff are available in the health facilities. The biggest transformation will come if wriggling out of postings and manipulating things through political patrons stops. The doctors will fall in line only if postings are notiied through a transparent and fair process and no exceptions whatsoever are allowed. Only the state Chief Ministers and Health Ministers can make this happen. q But will they?
(E-mail : chandra_shailaja@yahoo.co.in) 7

farmed out to private insurance companies and HMOs (Health Management Organisations) as a recent report on Universal Health Coverage seems to suggest. Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention. The National Rural Health Mission (NRHM) which is a public-sector programme has registered an encouraging impact in even the most intractable regions of the country. A UNFPA study has shown that nearly three quarters of all births in Madhya Pradesh and Odisha had been conducted in a regular health facility. The percentage of institutional deliveries in Rajasthan, Bihar in Uttar Pradesh was lower but even so, accounted for almost half the deliveries conducted in those states. Indeed these achievements are immense. Having said this, institutional deliveries alone cannot be the answer to all the problems that beset the rural health sector. A visit to any interior block or taluka in the Hindi belt states shows that
YOJANA October 2012

most primary health centres beyond urban limits are bereft of doctors, except sporadically. Some state governments have taken to posting contractual AYUSH doctors engaged under NRHM to man the primary health centres. These doctors dispense allopathic drugs, prescribe and administer IV luids, injections and life-saving drugs, assisted by AYUSH pharmacists and nursing orderlies. This reality must be confronted. If an AYUSH doctor has been entrusted with the responsibility of running a primary health centre, and found in shape to handle the national programmes, the controversy over what AYUSH doctors can and cannot do must be settled. The trend of AYUSH doctors working in as registrars and second level physicians in private sector hospitals, clinics, and nursing homes is wide-spread in states like Uttar Pradesh, Maharashtra, and Punjab; so also in Delhi and Mumbai. The challenge lies in understanding what can be changed and what cannot be changed, without getting intimidated by protests from Medical Associations that will always protect their turf to retain primacy.

HEALTH AND NUTRITION

ANALYSIS

Occupational Lifestyle Diseases in India

Jomon Mathew

The emerging lifestyle diseases not only affect the economic conditions of the individuals but also the productivity of the economy which is going to be threatened dangerously in the near future

IFESTYLE DISEASE is one associated with the way a person or group of people lives. In other words, lifestyle diseases characterise those diseases whose occurrence is primarily based on the daily habits of people and are a result of an inappropriate relationship of people with their environment. These diseases include hypertension, heart diseases, stroke, diabetes, obesity, diseases associated with smoking and alcohol and drug abuse, cancer, chronic bronchitis, premature mortality etc. Lifestyle diseases which are also called diseases of longevity or diseases of civilisation interchangeably are diseases that appear to increase in frequency as countries become more industrialised and people live longer. There are several factors leading to the occurrence of lifestyle diseases including factors like bad food habits, physical inactivity, wrong body posture, and disturbed biological clock. However, the significant factor contributing to lifestyle diseases of the present day may be regarded as the occupational nature of the people. The occupational pattern in India has undergone drastic

changes in recent decades giving priority to IT and other similar services neglecting the very base of the agrarian culture. Along with these changes in occupation, the food habits of the society too changed that gradually caused the spread of several lifestyle diseases in our society. Mounting figures of lifestyle disorders Several studies have been conducted by different organisations to identify the magnitude of lifestyle diseases in India. According to a survey conducted by the Associated Chamber of Commerce and Industry (ASSOCHAM), 68 percent of working women in the age bracket of 21-52 years were found to be afflicted with lifestyle disorders such as obesity, depression, chronic backache, diabetes and hypertension. Another study by Preventive Healthcare and Corporate Female Workforce summarised that long hours of work under strict deadlines cause up to 75 percent of working women to suffer from depression or general anxiety disorder, compared to women with lesser levels of psychological demand at work. Women employed in sectors that demand more time like those in media, knowledge

The author is Assistant Professor of Economics, Department of Economics, University College, Thiruvananthapuram, Kerala. 46 YOJANA October 2012

process outsourcing and touring jobs are unable to take leave when they are unwell. These tensed and continuous working conditions force themselves to work mainly due to job insecurity, especially during the current inancial meltdown. In India, around 10 percent of adults suffer from hypertension while the country is home to 25-30 million diabetics. Three out of every 1,000 people suffer a stroke. IT sector has been playing dominant role in Indian economy both in terms of contribution to GDP and its employment generation capability. It was estimated that this sector has increased its contribution to Indias GDP from 1.2 percent in FY 1998 to 7.5 percent in FY 2012. Moreover, this sector has also led to massive employment generation. The industry continues to be a net employment generator - expected to add 230,000 jobs in FY 2012, thus providing direct employment to about 2.8 million, and indirectly employing 8.9 million people. Generally being a dominant player in the global outsourcing sector Indian IT sector has emerged to be a key development strategy. Due to the above factors, majority of Indian youth depend directly or indirectly on this priority sector. However, according to the findings of the study by ASSOCHAM, around 55 percent of young workforce engaged in Indias IT and ITES sector are stricken with lifestyle disorders due to factors like hectic work schedules, unhealthy eating habits, tight deadlines, irregular and associated stress. More than half of the respondents participated in the survey said that due to 24 x 7 working environment and irregular food timings they directly place orders to fast food outlets, street food vendors and roadside eateries operating outside their offices serving ready to eat high calorie
YOJANA October 2012

processed food items like noodles, burgers, pizza, and fried stuff like samosas along with aerated drinks, and coffee, etc. Sleeping disorders are alarmingly growing among the employees in the corporate work field. ASSOCHAM records that 78 percent of corporate employees suffer from sleeping disorders leading to Impact of Insomnia on Health and Productivity. Due to demanding schedules and high stress levels, nearly 78 percent of the corporate employees sleep less than 6 hours in a day which leads to sleep disorders amongst them. The report is based on the survey conducted in the major cities like Delhi, Mumbai, Kolkata, Chennai, Ahmedabad, Hyderabd, Pune, Chandigarh, Dehradun etc. As per ASSOCHAMS corporate employees survey result, 36 percent of the sample population are also suffering from obesity. It can be logically summarised that obesity alone can modify occupational morbidity, mortality and injury risks that can further affect workplace absence, disability, productivity and healthcare costs. Almost 21 percent of the sample corporate employees suffer from another serious lifestyle disease called depression. High blood pressure and diabetes are the fourth and ifth largest diseases with a share of 12 percent and 8 percent respectively as suffered among the corporate employees. A striking case of life style disorders found in the Indias most developed state, Kerala which is almost on par with some of the European countries and America in terms of development indictors. The state is fast emerging as the lifestyle diseases capital of India with the prevalence of hypertension, diabetes, obesity and other risk factors for heart disease reaching levels comparable to those in America, as revealed in a recent

study done by Dr K R Thankappan and his colleagues at the Achutha Menon Centre for Health Science Studies. It was found that overall prevalence of diabetes in Kerala is about 16.2 percent. This is estimated to be 50 percent higher than in the US, according to the results of the study published in the Indian Journal of Medical Research . High blood pressure is present in 32 percent people, comparable to recent estimates in the US. Close to 57 percent people studied had abnormal levels of cholesterol, while 39.5 percent had low HDL cholesterol. The prevalence of smoking in men and use of alcohol are dangerously growing in the state. This transition of the state to an era of life style diseases is driven by economic growth, urbanization and our changing food habits. Economic and productivity impact It is predicted that globally, deaths from non communicable diseases (NCD) will increase by 77 percent between 1990 and 2020 and that most of these deaths will occur in the developing regions of the world including India. These conditions not only cause enormous human suffering, they also threat the economies of many countries as they impact on the older and experienced members of the workforce. In India alone, heart ailments, stroke and diabetes are the most demanding ones which are expected to take away the countrys gross national income to a huge extent by the year 2015. As per the report, jointly prepared by the World Health Organization and the World Economic Forum, India will incur an accumulated loss of $236.6 billion by 2015 on account of unhealthy lifestyles and faulty diet. The resultant chronic diseases like heart disease, stroke, cancer, diabetes and respiratory
47

infections which are ailments of long duration and slow progression, will severely affect peoples earnings. The income loss to Indians because of these diseases, which was $8.7 billion in 2005, is projected to rise to $54 billion in 2015. ASSOCHAMs healthcare survey further reveals that 41 percent of employees spend in the range of Rs.500-5000 on health care in a inancial year. Over 36 percent of the survey respondents say that they spend less than Rs. 500 on their health expenditure in a year. 21 percent of the employees health expenditure ranged between Rs. 5,000-50000, as they suffered from diabetes, acute liver disease, kidney disease, high blood pressure and stroke. Merely 2 percent of the employees spend more than Rs. 50,000 due to heart disease, paralytic attack, surgery etc. Indias rapid economic growth could be slowed by a sharp rise in the prevalence of heart disease, stroke and diabetes, and the successful information technology industry is likely to be the hardest hit. So-called lifestyle diseases are estimated to have wiped $ 9 billion off the countrys national income in 2005, but the cost could reach more than 100 billion over the next 10 years if corrective action is not taken soon. The study by the

Indian Council for Research on International Economic Relations says that although Indias boom has brought spiralling corporate profits and higher incomes for employees, it has also led to a surge in workplace stress and lifestyle diseases. The emerging lifestyle diseases not only affect the economic conditions of the individuals but also the productivity of the economy which is going to be threatened dangerously in the near future. As majority of employees especially those in the IT sector suffer from different types of health disorders and obesity, the productivity that depends on the efficiency and enthusiastic involvement of youth may in all way have to be compromised. The wrong choice of occupation in the blind run for higher salaries and the resultantly developing food habits generate all kinds of evil effects to the health of our youth. Over exploitation of the potentials of our youth particularly those in the IT sector may in course of time depreciate their eficiency and productivity leading to poor economic performance of the economy. Concluding remarks A healthy lifestyle must be adopted to combat these diseases

with a proper balanced diet, physical activity and by giving due respect to biological clock. To decrease the ailments caused by occupational postures, one should avoid long sitting hours and should take frequent breaks for stretching or for other works involving physical movements. In this revolutionised era we cannot stop doing the developmental work, but we can certainly reduce our ailments by incorporating these simple and effective measures to our lives. The working conditions especially in the IT sector should be properly monitored assuring that the potentials of our youth are not overexploited by the corporate proit motive employers. Moreover, the consumption pattern giving priority to fast food culture has to be effectively controlled. Even though, consumerism increases spending and boosts a countrys economy therefore increases its status around the globe, the evidence presented demonstrates the effects of unregulated consumption in modern society. Here is the role the media, marketers and social class play in moulding an individuals identity, protecting their good health and the efficiency and productivity of nations huge human resources. q
(E-mail: jomonmathew.k@rediffmail.com)

YOJANA
Forthcoming Issues
November Issues Concerning Children December North East Focus : Nagaland (Special Issue)
48 YOJANA October 2012

November 2012 & December 2012

65 YEARS OF INDEPENDENCE
INTERVENTIONS

Towards a Healthier India

Ambrish Kumar

The health system goals of equity and accessibility necessitate adoption of a inancing strategy that will ensure protection of the majority of individuals from catastrophic health expenditure

HE VALUE of healthy choices has been known to people living in Indian subcontinent s i n c e a n t i q u i t y. Ayurveda (science of life) is one of the oldest healthcare systems that take a holistic view of the physical, mental, spiritual and social aspects of human life, health and disease. While Indian systems have been effective in preventive healthcare, there are emergency situations where one requires surgical procedures. Management of diseases and patient care may need different approach and solutions.

We present the outcomes of the Health Planning in the country in two periods (1951-1979) & (19802012) spanning about 28 and 32 years respectively. 1st Five Year Plan (1951-56) to 5th Five Year Plan (19741979) The 1st Five Year Plan to 5th ive year plan were based on the recommendations of the Bhore Committee (1946), Mudaliar Committee (1961) etc. The importance of Health as a resource was well explained. The First Five Year Plan stated: Health is fundamental to national progress in any sphere. In terms of resources for economic development, nothing can be considered of higher importance than the health of the people. For the eficiency of industry and of agriculture, the health of the worker is an essential consideration. Health is a positive state of well-being in which the harmonious development of physical and mental capacities of the individual lead to the enjoyment of a rich and full life. All-India Institute of Medical Sciences (AIIMS), Delhi was established in 1956 as an institution of national

Access to Affordable Healthcare At the time of the independence, very few modern health care services were available. People depended on locally available traditional knowledge. State of public health was very low. All the population based health indicators, i.e., life expectancy, IMR, MMR, morbidity and mortality due to infectious and communicable diseases were highly unsatisfactory. Poor nutrition, unsafe drinking water, poor hygiene and living conditions contributed to poor state of public health.

The author is Adviser (Health), Planning Commission. 34 YOJANA August 2012

importance by an Act of Parliament with the objects to develop patterns of teaching in Undergraduate and Post-graduate Medical Education in all its branches so as to demonstrate a high standard of Medical Education in India; to bring together in one place educational facilities of the highest order for the training of personnel in all important branches of health activity; and to attain self-suficiency in Post-graduate Medical Education. Some notable achievements The life expectancy at birth went up from about 32 years as per 1951 Census to about 52 years during 197681. The infant mortality rate came down from 146 during the ifties to 110 in 1981. About 50,000 sub-centres, 5,400 primary health centres including 340 upgraded primary health centres with 30 bedded hospitals, 106 medical colleges with admission capacity of 11,000 per annum and about 5 lakh hospital beds were established. The country was declared free from smallpox in April, 1977. 6th Five Year Plan (19801985) to 11th Five Year Plan (2007-12) The main focus of the health planning during this period (1980-2007) was improving the availability of Health Human resources building rural health infrastructure, improving the availability of medicines and other services. National Health Policy 1983 & 2002 Indias first National Health Policy was formulated in 1983 and second in 2003. The main objective of this policy was to achieve an acceptable standard of good health. The NHP 2002 noted that the Central Government will have to play a key role in augmenting public health investments as the State Governments were in
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dificult iscal situation. This policy further envisaged a key role for the Central Government in designing national programmes with the active participation of the State Governments. National Rural Health Mission (NRHM): Healthy Villages NRHM was launched in April 2005 with the objective of providing accessible, affordable and quality healthcare to the rural population. Most prominent features of NRHM are involvement of communities in planning and monitoring, provision of untied grants to the health facilities and the communities annually, placing a trained female health activist in each village for 1000 population known as Accredited Social Health Activist (ASHA) to act as a link between the public health system and the community and bottomup planning. The programme is continuing in 12th Five Year Plan with few changes. Under the NRHM the following interventions have been initiated: l Janani Suraksha Scheme (JSY): Janani Suraksha Yojana (JSY) is a conditional cash transfer scheme resulted in dramatic increases in institutional delivery. The JSY encourages women to make use of public health facilities for safe delivery. l JananiShishu Suraksha Karyakram (JSSK): JSSK is a new initiative to make available better health facilities for women and child. All pregnant women delivering in public health institutions will have absolutely free and no expense delivery, including caesarean section. The scheme is estimated to beneit more than 12 million pregnant women who access Government health facilities.

Mother and Child Tracking System(MCTS): Tracking of Pregnant mothers and children has been recognized as a priority area for providing effective healthcare services. Mother and Child Tracking system (MCH) is a name based pregnant mother and child tracking system. It is a management tool to reduce MMR/IMR/TFR and track the health service delivery at the individual level. MCTS supports health and family welfare managers and policy makers in measuring and monitoring the eficiency of the maternal and child health services in terms of needs, effectiveness and capacity, eficiency and evaluating up to what extent the increase in eficiency in the delivery of maternal and child health services has contributed to the decrease in maternal, infant and child mortality. Universal Immunization Programme (UIP): Routine Immunization: The UIP protects infants against six vaccine preventable diseases viz., tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles. The standard immunization schedule developed for the child immunization programme speciies the age at which each vaccine is to be administered and the number of doses to be given. Routine vaccinations received by infants and children are recorded on a vaccination card issued to a child. The establishment of a Technology Mission on Immunization in 1986 provided extra impetus and coverage increased rapidly. At the all-India level, 61 percent of children aged 12-23 months received full immunization.
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The coverage of immunization was higher in urban areas (67.4 percent) compared to that in rural areas (58.5 percent). About 8 percent of the children did not receive even a single vaccine. (UNICEF: Coverage Evaluation Survey 2009). Routine immunization contributes significantly to reducing under ive mortality and morbidity. Prevention and Control of Diseases India is faced with the triple burden of diseases. Communicable diseases continue to be a major public health problem in India. Many communicable diseases are endemic. There is always a threat of new emerging and re-emerging infectious diseases like, avian inluenza, SARS, H1N1 inluenza, etc. Local or widespread outbreaks of these diseases result in high morbidity& mortality. India is witnessing a rising incidence of non-communicable diseases (NCDs), and old age diseases. Mental Health is another area which needs urgent intervention. This rise is occurring in a setting where health expenditures are growing rapidly led by an unregulated private sector and where health insurance and pension coverage are still limited. Noncommunicable Diseases (NCDs) account for nearly half of all deaths in India. Among the NCDs, Cardiovascular Diseases (CVD) account for 52 percent of mortality (52 percent) followed by Chronic Obstructive Pulmonary Disease (COPD), Cancer, Diabetes and Injuries. High cost of medicines and longer duration of treatment NCDs constitute a greater inancial burden. Roa d tr a ff ic in ju r ie s a r e increasing sharply. Injuries and diseases of the musculoskeletal system account for more than 20
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percent of patient visits to primary care. Health-damaging behaviours such as smoking, drinking, consuming unhealthy diets (rich in salt, sugar and fats). National Urban Health Mission: Healthy Cities A new National Urban Health Mission to focus on the health challenges of people in towns and cities is needed. The NUHM will focus on health needs of the urban poor, particularly the slum dwellers by making available essential primary health care services. Health Human Resources and Tertiary Care Institutions Shortage of medical teachers, PG specialists and super-specialists is acute, which lead to adverse impact on the quality of education and patient care. The tertiary healthcare institutions have expanded significantly during the last 2025 years, mainly through private sector. However quality and cost of education is a cause of concern. The corporate hospitals came into existence after the government allowed private participation and investment in hospitals. The entry of corporate sector into the Indian healthcare industry has improved high-tech infrastructure and raised the quality of services. As a lip side, it has taken away many high performing doctors from public health system to private sector owing to high remuneration, state of art technology and general working environment. Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) PMSSY was launched in 2006 with the objective of correcting the imbalances in availability of affordable/reliable tertiary level healthcare in the country in general and to augment facilities for quality medical education in the under-served States. The

PMSSY envisages setting up eight AIIMS like institutions (ALIs). Each institution will have a 960 bedded hospital in 39 specialty /super-specialty disciplines. Medical College has 100 UG intakes. PMSSY also envisaged up-gradation of existing medical institutions. States Performance in the Health Sector India is a union of 28 states and 7 union territories. Within the country, there is persistence of extreme inequality and disparity both in terms of access to care as well as health outcomes. There are some states like Kerala, Tamil Nadu who have been performing well whereas in some states, rate of improvement is insuficient to catch the better performing states in near future. Life expectancy at birth (or longevity) is an overall indicator of the economic and social wellbeing of the people. As a society advances, the life expectancy of its people also increases. The IMR and MMR are a sensitive indicator of not only the health status of the population but also the level of human development. Keralas lifeexpectancy at birth is about 10 years more than that of Assam. IMRs in MP and Orissa are about ive times that of Kerala. Annual Health Survey Bulletin 2010-11 reports that, IMR across 284 districts ranges between 19 (Rudraprayag; Uttarakhand) and 103 (Shrawasti, UP) a variability of 5 times. Similarly MMR across 284 districts ranges between 11 (Rudraprayag; Uttarakhand) and 75 (Balangir, Odisha) a variability of 7 times. MMR in UP is more than four times that of Kerala. MMR estimates for the country for 2007-09 is 212, in (EAG) states and Assam 308 and among Southern States it is 127, in other states it is 149. This high degree of variation of health indices is a relection of the
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high variance in the availability of health services in different parts of the country. The challenge is to provide these areas with access to low-cost public health interventions and timely treatment. These States are also the ones that have acute crises of human and financial resources. This large disparity across India places the burden on the poor, especially women, scheduled castes, and tribes. Public Health Expenditure Financing healthcare is one of the critical determinants that inluence health outcomes in a country. The health system goals of equity and accessibility necessitate adoption of a financing strategy that will ensure protection of the majority of individuals from catastrophic health expenditure. National Health Accounts (NHA): India 2004-05 shows that the health care system in India is predominantly catered by the private sector. Expenditure in the private sector contributes to 78.05 percent of total health expenditure, public sector accounts for 19.67 percent and external flows 2.28 percent. Health expenditure formed 4.25 percent of Gross Domestic Product (GDP). By source, Central Government accounted for 6.78 percent while State Governments contributed 12 percent. Under private expenditure, households contribute a significant portion at 71.13 percent of total health expenditure with social insurance funds at 1.13 percent and irms at 5.73 percent. Health expenditure as percentage of GDP and public spending as percentage of total health Expenditure is low when compared to developed countries. The total public expenditure on health as a percent of GDP stands at around 1.1 percent in 2009-10. The state share of public expenditure
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on health 0.70 percent, whereas the central share 0.39 percent. Total Health Expenditure (both public and private combined) as percentage of GDP in India is higher than China, Malaysia, Sri Lanka, Thailand, Pakistan and Bangladesh though public spending as percentage of total health expenditure is signiicantly lower than all these countries. After the launch of NRHM there has been increase in state health expenditure. Most of this is in the non-plan. States are required to contribute 15 percent of the cost of the NRHM. Most states spend around 4 to 5 percent of the state budgetary outlay on health and less than 1 percent of the GSDP on health-which is insuficient to meet the NRHM goals. Financial Protection and Health Insurance India ranks very low in terms of inancial protection. The high Out of Pocket (OOP) expenditure on health care forms a barrier to accessing care and can cause households to incur catastrophic expenditures, which in turn can push them into indebtedness and poverty. A consequence of the low public spending on health is the extremely high burden of private out-of pocket expenditures. Indias medical insurance sector remains weak and fragmented even though there is a plethora of medical insurance schemes operated by the Central (RSBY) and state governments (Arogyasri) , public and private insurance companies and several community-based organizations. Ayush AYUSH has presence in all parts of the country. It has near universal acceptance, available practitioners and infrastructure. The strength of AYUSH system lies in preventive & promotive health

care, diseases and health conditions relating to women and children, non-communicable diseases, stress management, palliative care, rehabilitation etc. AYUSH has very little side effect, has a soft environmental footprint and is engrained in local temperament. It can play an important role in achieving the National Health Outcome Goals. Its huge resource of hospitals beds (62,000), and health workers (7.85 lakhs) need to be eficiently utilized to meet the National Health outcome Goals. AYUSH and Allopathic, both systems, often provide solutions to a common set of problems. Many times both systems complement each other also. Our endeavor during the 12th Five Plan period should be that both systems expand and progress together, based on their core competencies and inherent strengths. We must ensure that the Health care delivery system in the country is designed and developed in such a way that, both, AYUSH and allopathic systems are available to every patient and the choice of system of treatment is the patients choice. Achievements and Areas of Concern During 1980-2012 (about 32 years), India registered signiicant progress in improving life expectancy at birth, reducing mortality due to communicable diseases, as well as reducing infant and material mortality. One of the major achievements during this period is non-reporting of polio cases from any part of the country for more than 12 months. However, a high proportion of the population, continue to suffer and die from preventable diseases, pregnancy and child birth related complications as well as malnutrition. The rural and urban both public health care system in many States and regions is in
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an unsatisfactory state leading to pauperization of poor households due to expensive private sector health care. IMR and MMR are showing downward trend, yet the rate of improvement has to be two to three times that in the past so as to attain the monitorable goals. We have not been able to address social and family health issues such as Malnutrition of woman and children, declining child sex ratio (CSR), adolescent health, care of older persons etc. Health is a state subject. All stakeholders need to co-operate and communicate for efficient and effective management of the programme. Managerial capacity of the Health programme managers needs to be strengthened, upgraded, and modernized. Fully functional health care facility at a reasonable distance and location is a dream for most of the population. All the three connectivity i.e. Road, Mobile and Internet are essential for eficient functioning. To address issue of large inter-district variations, decentralized district-based health planning is essential. It may be noted that Only Healthy people will enjoy Demographic Dividend. 12th Five Year Plan: (2012-2017): Towards Comprehensive Health Care As per census 2011, total population of the country is 1210.2 million. Out of which, Rural population is 833.1 million (68.84 percent) and Urban 377.1 million (31.16 percent). During 2001 2011, population of the country has increased by 181.4 million. Population increase in rural areas is 90.4 million and in urban is 91.0 million. Number of Rural Units (or Villages) in India are 6, 40,867, an increase of 2,279. The number of
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Urban Units is 7,935, an increase of 2,774. Out of which Statutory Towns are 4,041 an increase of 242 and Census Towns 3,894 an increase of 2,532. There are large differences between Rural and Urban Health indicators and also between Male and Female indicators. As per SRS Bulletin, December 2011, IMR in 2010 was 47 (total), 46 (male) and 49 (female) respectively. In rural areas corresponding numbers were 51 (T), 50 (M) and 53 (F) and in urban areas 31 (T), 30 (M) and 33 (F). The gap between urban male and rural female is 23 points. AHS Bulletin 2010-11 observes that IMR in rural area is signiicantly higher than that of urban area. In UP, rural IMR is 74 compared to 54 in urban. More female infants die as compared to males. In UP, female IMR is 72 compared to 69 for males. Planning Commission constituted the High Level Expert Gro up (HLEG) on Universal Health Coverage (UHC) under the Chairmanship of Dr K. Srinath Reddy in October 2010 to draw and design a comprehensive strategy for health for the Twelfth Five Plan. Some of the Recommendations of HLEG are as follows: l Ensuring equitable access to affordable, accountable, appropriate health services of assured quality as well as public health services addressing the wider determinants of health delivered to individuals and populations; l Universal entitlement to comprehensive health security; l Government (Central government and states combined) should increase public expenditures on health from the current level of 1.2 percent of GDP to at least 2.5 percent by the end of the 12th

l l l

plan, and to at least 3 percent of GDP by 2022; Ensure availability of free essential medicines by increasing public spending on drug procurement; Use general taxation as the principal source of funding health care; Three Year Bachelors Degrees for Rural Health; Emphasize Public Health: Investing in public health is the cheapest way of promoting the health well-being of the population; Highly uneven distribution of medical colleges resulted in the skewed production and unequal availability of doctors across the country. Setting up of 187 new medical colleges and 382 new nursing schools over the next 10 years in underserved districts; Regulation of the public and the private sectors to ensure provision of assured quality and rational pricing of health care services.

The Twelfth Five Year Plan adopts a broad approach to health, including as key determinants of health, a range of resources like food supply chains and nutrition, drinking water and sanitation. It takes the view that health would entail a continuum of care across sectors. Accordingly, the health policy and programmes will encourage a multi-sectoral approach to health. It also recommends strategic changes to the existing health programmes and schemes, such that they work in conjunction with each other and collectively contribute to building a comprehensive health system. Thus it brings into focus a systemic approach to health, while recognizing the importance of the individual programmes. q
(E-mail :ambrish.kumar@nic.in) YOJANA August 2012