HEALTH SECTOR OF KERALA AND PERSPECTIVE PLAN

Dr. Manju S.Nair

KERALA PERSPECTIVE PLAN

The KPP 2030 is a GoK initiative that will serve as the basis for implementation of a series of initiatives aimed at fostering sustainable and inclusive growth of the economy.

Outcome based strategic planning Identifies development challenges and

outlines high quality planning to achieve the goals

Situation analysis, vision, mission, goals, strategies

PERSPECTIVE PLANNING IN THE HEALTH SECTOR Situation analysis- summary of Kerala’s

achievements Then identifies the major health

challenges as 1. Health Status 2. Health Infrastructure 3. Health Financing

HEALTH STATUS Health indicators not on par with

developed nations Increasing incidence of communicable

and non communicable diseases Gender issues Ageing and age related health issues

HEALTH INFRASTRUCTURE Inadequate infrastructure in terms of

hospital, beds, doctors and nurses Declining primary health centres and

community health centres

HEALTH FINANCING Increasing out of pocket expenditure Increasing per capita health expenditure Health expenditure as percentage of

GSDP

HEALTH STRATEGIC PLAN-VISION ‘Kerala will ensure “health for all” by 2030. It will provide health security provision to

each and everyone by 2030. It will have a highly innovative, affordable,

and accessible health system that all Keralites can trust.

It will have a health system that is accessible when people need it, regardless of their ability to pay.

Kerala would also be able to establish in the global health care services market generating foreign exchange and driving its growth process

MISSION 2030 Good health and well being for all Keralites

throughout their lives Timely and equitable access for all Keralites

to a comprehensive range of health and disability services, regardless of their ability to pay

A high performing system in which people have confidence

Active involvement of consumers and communities

Transformation of the health sector into a growth driving sector by positioning it in the international health care services market.

GOALS 1. Health for all Increase the health expenditure to GSDP

ratio from 0.6 per cent in 2012 to 4-5 per cent by 2030. This will be achieved by one per cent point increase spread over the next five year plans

Reduce MMR from 81 to 12 per lakh live births

Reduce IMR from 13 to 6 per 1000 live births Eradicate communicable diseases Prioritise health areas to include mental

diseases, alcoholism and suicides

Increase the number of hospital beds from 34 per 10,000 in 2004 to 70 by 2030

Increase the number of nurses from 12.4 in 2004 to 65 by 2030.

Increase the number of doctors from 9.9 per 10,000 population to 17 in 2030.

Provide health insurance cover to all 2. Promote health hubs Set up three medical cities by 2030.

THE STRATEGIC FRAMEWORK Four pillars 1. Economic prosperity through health 2. Enhance human capital by promoting

world class facilities 3. Social health 4. Natural and environmental capital

ECONOMIC PROSPERITY THROUGH HEALTH – ACTION PLAN 1. create global health cities 2. international bench marking 3. promote Research and Development

Medical tourism, FDI, MNCS Will it create a health system that is

accessible when people need it, regardless of their ability to pay.

ENHANCE HUMAN CAPITAL BY PROMOTING WORLD CLASS FACILITIES – ACTION PLAN

Promote health education

students from other countries will be attracted to the cities promoting medical services

SOCIAL HEALTH – ACTION PLANS 1. health promotion through self care and

community participation 2. strengthen health care services –

should be inclusive in nature, for that public –private partnership in ensuring quality health care services.

Health care services in public health care facilities may be franchised to private players.

Performance linked compensation to health workers in specific government run programme

3. alternative systems of medicine 4. facilitate health financing – a small

write up on RSBY and a small note on Health Voucher Scheme for the poor

5. increase public investment in health sector – mere lip service

IV NATURAL AND ENVIRONMENTAL CAPITAL – ACTION PLAN The strategy for Hospital Common

Waste (HWC) management will require a ‘Bio Medical Waste Management Legislation’, supervised together by the state Department of Health and Department of Environment. This legislation will be comprehensive with detailed policies on

Facilities and procedures, labelling, treatment, transport, inspections. Fees etc.

PP IN HEALTH SECTOR : A CRITIQUE If the vision is health for all Strategy will be an utter failure It will wipe out all the health

achievements that Kerala has earned throughout its plan process

Doesn’t take into consideration any of the ground realities

Just to convert health system into a corporate system

Leaving the importance of public health system – only curative that too expensive and not preventive

Health care will become inappropriate to the vast majority of the Keralites, not only for the poor but for the rich also

Out of pocket expenditure and catastrophic health expenditure.

Health care induced poverty will be the major type of poverty in Kerala by 2030.

‘good health at low cost’ will be converted to ‘bad health at exorbitant cost’

A HEALTH CHECK UP Kerala has achieved commendable

progress in health – CDR, IMR, LE Kerala model – ‘good health at low cost’ It was possible at low level of resources

to achieve laudable health status, at least by measures of mortality and gross morbidity

Kerala became a model for the right kind of social policies – which would ensure balanced and equitable development and steady improvement in health indices

This health development generally attributed to

spread of education, especially female education,

political awareness development of road networks and

transportation social movements

Historical factors struggle for social reforms agrarian reforms Improvement in the social living conditions

of the landless poor in the rural areas public distribution system. At the time of formation of the present

Kerala state on 1 November, 1956, the foundation for a medical system accessible to all citizens were already laid

the proportion of government expenditure set apart for health.

government health expenditure -13.04 percent

government expenditure - 12.45 percent state domestic product at 9.81 percent. From 1961 to 1986, the state generally

expanded its government health facilities. The number of beds and institutions

increased sharply. The total number of beds in government

hospitals in the western medical sector increased from around 13,000 in 1960-61 to 20,000 in 1970-71, and 29,000 in 1980-81.

CRISIS IN KERALA’S HEALTH SECTOR By 2000 – increasing burden of diseases Mediflation Now, Kerala’s health care dependent on

one’s ability to pay, though with no assurance to quality

This is against a model which was once characterised by health security, whatever one’s socio economic position, the state used to provide health care

CRISIS IN KERALA’S HEALTH SECTOR The state, which set an example for the

rest of India and third world countries in providing primary health care, now gropes in the dark and is fast losing the edge

The great achievements in the field of mortality and fertility have reached a plateau and the morbidity rates and increasing.

It can no more be called as ‘good health at low cost’

Kerala on the brink of a public health crisis

INCREASING BURDEN OF DISEASES

epidemiologic transition Kerala is now passing through the third

stage of epidemiological transition Life style diseases But, some communicable diseases have

re-emerged and some new epidemics have emerged in the state.

COMMUNICABLE DISEASES

Waterborne diseases diarrhoea (per 10,000) increased from

14.14 percent in 2011 to 19.76 in 2012. Leptospirosis - 7.4 and 2.2 percent of the

total people infected had succumbed to death in 2011 and 2012 respectively.

Vector Borne diseases Dengue fever, Malaria, Chikungunia, H1N1 and Japanese Encephalitis are still

remaining as seasonal threats.

 

Disease 2007 2008 2009 2010 2011

Malaria 1927 1804 20466 2199 2334

Dengue 677 733 1425 2597 1304

Chickungunia 24052 24685 13349 1531 1708

Hepatitis A 5350 6963 7844 5181 5122

Leptospirosis 1359 1305 1237 1016 976

H1N1 fever 1578 1534 567

HIV epidemic in Kerala is distinctly related to migration.

HIV prevalence rate in the general population is 0.26.

The estimated number of people infected with HIV in Kerala is 55167. A total of 10846 cases and 1719 deaths were reported in 2011

NON COMMUNICABLE DISEASES

Kerala is witnessing a rising incidence of non-communicable diseases and old age diseases.

In the age group between 30 and 60, more than 50 per cent of death occurs as a result of NCDs.

These include diseases such as heart disease, stroke, high blood pressure, cancer and stroke.

on an average 110 individuals are dying of cardiovascular diseases daily in the state.

Cardiovascular diseases results in 50 percent of total deaths in the state.

It is expected that by 2020, the death tally in the state as a result of cardiological complaints will increase to two third.

Kerala has the highest prevalence of coronary artery diseases in India. Prevalence rate of coronary artery diseases is 7.5 in rural areas and 12 percent in urban areas.

52.1 percent of males and 61.4 percent of females in Kerala have a cholesterol level greater than 200 milligrams per decilitre (mg/dl).

Kerala has the highest number of diabetic cases in India with 27 percent of the males and 19 percent of the females

One out of every three individuals in Kerala has hypertension.

Diseases like diabetes and cancer had increased the level of mental stress in the state which resulted in the prevalence of hypertension in Kerala.

Cancer shows an ever increasing trend in recent years.

more than 35,000 thousand new cases of cancer are reported annually.

Around one lakh patients are under treatment every year in various hospitals

The prevalence rate of chronic respiratory illness increased in 2012 to 305.12 per ten thousand from 233.88 in 2011.

ACCIDENTS AND INJURY

As per State Crime Records Bureau (2012), a total of 35216 accidents occurred in the state in 2011, which resulted in the death of 4,145 individuals.

25,110 were seriously wounded another 16,269 suffered from minor

injuries

MENTAL HEALTH Recent studies of Kerala State Mental Health

Authority show that 4.5 lakh people in Kerala have mental illness like schizophrenia, mood disorder, profound mental retardation and severe personality problems.

Social stigmatization of mental patients is also a problem faced by the health care sector in the state.

Suicide rate in Kerala is increasing at an alarming rate. 0.4 to 0.9% of all deaths in the hospitals and 0.3 to 1% all casualty admissions are following suicidal attempt (KSMHA, 2009).

The suicide rate in Kerala in 2011 is 25.3 per lakh with an aggregate registered case of 8431.

Alcohol and drug related health problems are very high in the state.

In the year 2012-13, the overall sales touched an all time high.

With regard to per capita liquor consumption, Kerala is at third position in India after Maharashtra and Punjab.

Divorce rate in Kerala is much higher than other states in India.

In the year 2012, a total of 16,917 divorce cases in the state.

AGEING

The proportion of aged in total population had increased from 5.8 percent in 1961 to 10.8 (10 percent of male and 11.62 percent of females in total population).

As per the projected figures, by the year 2021, the proportion of aged people in the population will reach 16 percent and by 2051, the same will reach 30 percent.

Among all age groups, the fastest growing group is the old old (66-79 years). The oldest old (80 and above) also shows an increasing trend.

The dependency rate of elderly people in Kerala is also showing an increasing trend in recent years

16 percent of the elderly folk are supported by 42.2 percent of the working age population

Leaving the whole sort of issues to be tackled by the MNC aided global health cities

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Plan period State’s total outlay Outlay on

health

% of health

outlay on total outlay

First plan 3003.00 192.00 6.39

Second plan 8700.71 874.74 9.74

Third plan 17000.00 1340.00 7.94

Annual plans 14437.00 495.00 3.43

Forth plan 25840.00 1044.00 4.04

Fifth plan 56890.00 1249.00 2.19

Annual plans 42870.00 903.00 2.11

Sixth plan 155040.00 3595.60 2.32

Seventh plan 210000.00 5050.00 2.40

Annual plan 66020.00 1700.00 2.57

Annual plan 77500.00 1955.00 2.52

Eighth plan 546000.00 12000.00 2.20

Ninth plan 1610000.00 30940.00 3.06

Tenth plan 2400000.00 40840.00 2.60

Eleventh plan 4042200.00 96569.00 2.39

PUBLIC AND PRIVATE EXPENDITURE ON HEALTH

State Percentage of

public

expenditure

Percentage of

private

expenditure

State Percentage of

public

expenditure

Percentage of

private

expenditure

Himachal

Pradesh

37.8 62.2 Gujarat 18.0 82.0

Assam 30.9 69.1 Andhra

Pradesh

17.5 82.5

Rajastan 30.4 69.6 Punjab 16.8 83.2

Karnataka 28.9 71.1 Madhya

Pradesh

15.2 84.8

Jammu &

Kashmir

25.5 74.5 Kerala 12.9 87.1

Tamil Nadu 23.9 76.1 Bihar 11.8 88.2

West Bengal 23.4 76.6 Haryana 10.4 89.6

Orissa 23.0 77.0 Utter Pradesh 7.5 92.5

Maharashtra 19.4 80.6

GROWTH OF PRIVATE SECTOR

Private hospitals now surpass government facilities in the density of beds and employment of personnel.

More significantly, private hospitals have far outpaced government facilities in the provision of hi tech methods of diagnosis and therapy, such as computerized tomography (CT) scans, endoscopy units, magnetic resonance imaging (MRI), neonatal care units, coronary units etc.

factors outside the health sector could have facilitated the growth in the private sector.

rising disposable incomes lack of barriers to opening a private

hospital. the ageing of the population. reflected in the higher proportion of

chronic diseases among them and their higher spending on health care.

SPIRALING OUT OF THE POCKET EXPENDITURE

According to KSSP’s study, on an average, in Kerala, a person spends almost Rs. 6,000 an year out of his own pocket to seek medical care.

This is four times the amount that a person used to spend from his pocket on health six years ago.

(KSSP’s similar study in 2004 put the average own expense on health at Rs. 1,500).

When this figure - Rs. 6,000 – is projected against the State’s total population, the people in Kerala are spending a mammoth Rs. 19,000 cr. plus annually from their own pockets for health care.

This is apart from what the Government is currently spending on health care

The average annual out-of-pocket spending by a person with chronic illnesses was about Rs. 38,000.

The average out-of-pocket expenditure of a person in visiting OP (out-patient) clinics in the Government sector was Rs. 4,034 in an year. In the private sector, this OP expense was not very different at Rs. 4,739.

However, when it came to IP expenditure (in-patient), the average annual out-of-pocket expenditure was Rs. 6,267 against the figure of Rs. 30,800 in the private sector. Here again, this escalation in expenditure was mostly due to the involvement of expensive corporate hospitals.

CATASTROPHIC HEALTH CARE EXPENDITURE

MALNUTRITION

According to the National Family Health Survey India - 3 (NFHS – 3), with regard to Kerala:

56.1% children aged between 6-35 months are anemic

32.7 % ever-married women aged between 15-49 are anemic

33.8% pregnant women aged between 15-49 are anemic.

Infant mortality is estimated at 15 deaths before the age of one year per 1,000

Under-five mortality is 16 deaths per 1,000.

Perinatal mortality, which includes stillbirths and very early infant deaths (in

the first week of life), is estimated at 11 deaths per 1,000 pregnancies

Perinatal mortality in rural areas, at 15, is much higher than the rate in urban areas.

As per the Audit Report (General and Social Sector) for the year ended 21March 2013, the percentage of malnourished children below the age of six years in the State ranged between 27 and 39.

Test check of records in Idukki, Malappuram,

Palakkad and Thiruvananthapuram districts indicated that 110 out of 1180 children who died during 2011-12, were severely malnourished.

the number of severely malnourished children in Palakkad was 4,633

the Auditor General in its report on ICDS

The percentage of child population who were not immunized against Polio and DPT in Palakkad and Malappuram districts were respectively 36 and 31.

The objective of universalization of Supplementary Nutrition Programme was not achieved as 56 to 66 per cent of the identified beneficiaries were not covered under the Scheme.

While the `Kerala Development Model’ gained national and international appreciation as an adaptable development ideal, the experiences of the marginalized of Kerala was entirely excluded from the much acclaimed statistical information and academic studies.

Human Development Report 2005, which while discussing horizontal inequalities that persist in Kerala among Dalits, Adivasis and fishing communities, pointed out that:

“….There is no denying one’s location within the network of social affiliation substantially affects one’s access to resources…”.

Tellingly, NFHS-3 states that the infant mortality rate changes sharply with household wealth and is higher for women who belong to other backward classes.

ATTAPPADI EXPERIENCE The continuing deaths of children in the

Attappady Hills, Palakkad district in Kerala has shocked the conscience of the entire country

The death of even one child due to malnutrition is a tragedy

this constitute a serious human rights violation and a breach of constitutional obligations

If the state withdraws from the scene or goes for a public private partnership

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IF THE VISION IS HEALTH FOR ALL A society that is healthy Should meet the twin challenges of re-

emerging and emerging diseases Provide an environment that is

conducive to healthy life That can afford and willing to meet the

cost of health care Take care of the old and weak Regulate the unethical practices

MAJOR STRATEGIES SHOULD BE

I. ADDRESS THE SOCIAL DETERMINANTS OF HEALTH Clean drinking water Sanitation facilities Solid waste management Poverty Enforcement of regulation for good

health – food safety act and public health act

2. REORGANIZATION OF GOVERNMENT HEALTH SECTOR – ACTION PLANS

Linking the institutions in a networked care system

higher level of organisation and management

Revamping the primary care provider institutions, Community health centres, Taluk Head Quarters Hospital, District Hospitals and Medical College Hospitals

PRIMARY CARE Equipped to meet the new challenges –

NCDs, Mental health, geriatric care Population per SC – 5000 to be changed

to 3000 or go for a four tier system Or the SC and PHC should be enlarged PHC should have standard design with

patient waiting areas, separate and clean toilets, safe drinking water, examination room that respect the privacy of patients and a lab that offers all routine investigation

More medical officers

COMMUNITY HEALTH CENTRE Must be the source of specialist

treatment. CHC should have facilities in pediatrics, general surgery, gynecology, obstetrics and general medicine

Facilities at the CHC would be utilized as a coordinating centre of pain and palliative care, terminal care and community mental health programme

TALUK HEAD QUARTERS HOSPITAL In addition to major specialities, other

specialities such as ortho, ENT, dentistry, dermatology, psychiatry, ophthalmology

Blood bank facilities and second level lab facilities should be provided

First level trauma management

DISTRICT HOSPITALS To be upgraded in view of the increasing

prevalence of NCDs and the challenge of managing co-morbidites

Dialysis, cardiac care, cancer care, neurological cases should be provided

Advanced laboratory facilities including CT scan should be provided

Doctors being offered PG and super specialty seats under government quota in Medical College should be earmarked for posting in district hospitals

Ayurveda Homeo Medical College hospitals – quality and

research.

3. HEALTH MAN POWER & MEDICAL EDUCATION TRAINING Systems to be devised to ensure that

person educated through public resources are available to serve the public should the need arise

The state can provide manpower for export or to meet the needs of private providers with government effectively discharging the regulation functions

Need for clinical specialty and super specialty seats in view of increasing demand for tertiary care

New courses are needed in geriatric, emergency and critical care and family medicine, M.Ed courses which enables specialty practices

Continuing medical education

4. GOVERNANCE OF THE SECTOR Develop and improve systems to ensure

governance of the health system A) establish a public health cadre B) improve regulatory environment C) system of multi sectoral collaboration D) addressing the special needs of

special population E) ensure quality of drugs and make

them affordable F) improve regulatory environment

5. STRATEGIES FOR SOLVING INCREASING MORBIDITY 1. control and management of communicable

diseases promotion of good health and prevention building a cadre of public health leaders levels of vaccination should be high enough to

ensure vaccine preventable diseases based on seasonality and epidemiology the

state should take advanced action to prevent the spread of diseases

need for formalising and strengthening structures such as the ward level health and sanitation committees and health standing committees of LSGs

2. Prevention and management of lifestyle related diseases.

a holistic approach leading from preventive action for the healthy, screening for the high risk population, primary care for the affected, tertiary for the acute cases and palliative care for the terminally ill patients

Prevention of accidents, trauma care Reduction of IMR, MMR etc Mental Health Health of the aged and palliative care

Thus if the KPP is aimed at fostering sustainable and inclusive growth of the economy the strategies visualised in the Perspective Plan 2030 will totally derail the whole system.

To be inclusive Growth must carry the many with it Secondly, it must satisfy the widest

range of our material needs It must address the binding constraints And the question of distribution - ie Are

the emerging opportunities being distributed equally

Growth does raise household incomes and helps to remove poverty, especially if health, education and other basic capabilities that enable people to participate in the growth process are widely shared

If KPP is followed Keralites will become the most ill healthy population in the world

There is a strong case for forceful public demand for much larger allocations to basic public services like health

The constructive use of public resources generated by economic growth to enhance human capabilities contributes not only to the quality of life but also to higher productivity and further growth