CHAPTERt–t1t

INTRODUCTIONt

1
 INTRODUCTION TO HEALTH CARE

Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness,

injury, and other physical and mental impairments in humans. Health care is delivered by

practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and

other care providers. It refers to the work done in providing primary care, secondary care and

tertiary care, as well as in public health.

Access to health care varies across countries, groups and individuals, largely influenced by

social and economic conditions as well as the health policies in place. Countries and

jurisdictions have different policies and plans in relation to the personal and population-based

health care goals within their societies. Health care systems are organizations established to

meet the health needs of target populations. Their exact configuration varies from country to

country. In some countries and jurisdictions, health care planning is distributed among market

participants, whereas in others planning is made more centrally among governments or other

coordinating bodies.

Health care can form a significant part of a country's economy. In 2008, the health care

industry consumed an average of 9.0 percent of the gross domestic product (GDP) across the

most developed OECD countries.[2] The United States (16.0%), France (11.2%), and

Switzerland (10.7%) were the top three spenders.

Health care is conventionally regarded as an important determinant in promoting the

general health and wellbeing of peoples around the world. An example of this is the

worldwide eradication of smallpox in 1980—declared by the WHO as the first disease in

human history to be completely eliminated by deliberate health care interventions.

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1.1 SECONDARY CARE

Secondary care is the health care services provided by medical specialists and other health

professionals who generally do not have first contact with patients

It includes acute care: necessary treatment for a short period of time for a brief but serious

illness, injury or other health condition, such as in a hospital emergency department. It also

includes skilled attendance during childbirth, intensive care, and medical imaging services.

The "secondary care" is sometimes used synonymously with "hospital care". However many

secondary care providers do not necessarily work in hospitals, such as psychiatristsor

physiotherapists, and some primary care services are delivered within hospitals. Depending

on the organization and policies of the national health system, patients may be required to see

a primary care provider for a referral before they can access secondary care.

For example in the United States, which operates under a mixed market health care system,

some physicians might voluntarily limit their practice to secondary care by requiring patients

to see a primary care provider first, or this restriction may be imposed under the terms of the

payment agreements in private/group health insurance plans. In other cases medical

specialists may see patients without a referral, and patients may decide whether self-referral

is preferred.

Allied health professionals, such as occupational therapists, speech therapists, and dietitians,

also generally work in secondary care, accessed through either patient self-referral or through

physician referral.

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1.2 Health care research

Health has been defined by World Health Organisation as “A state of complete

physical, mental and social well being and not merely the absence of disease or

infirmity”. Health is no longer a product of economic development rather it has

become an important determinant of the economic development of every nation.

Assuring a minimal level of healthcare to the population has become a critical

constituent of the development process. Unhealthy people can't be expected to make

any valid contributions towards the development programmes. World Health

Organisation (WHO) considers health to be a fundamental right of every human being.

The 'right to health' has been recognised in various national and international

instruments like Europeon Social Charter 1961, African Charter on Human and

People's Rights 1981. The right to health was further promoted internationally through

'Alma Ata Declaration' in 1978 where the 30th World Health Assembly resolved that

the main target in coming years for Governments, as for the WHO, should be „the

attainment by all citizens of the world by the year 2000 A.D. of a level of health that

will permit them to lead a socially and economically productive life‟ (WHO, 1979).

Even after seven decades of formation of WHO, there are many countries who have

still not made 'Right to Health' as a part of their constitution. In the South East Asian

region only Korea, Nepal, Thailand, Indonesia and Maldives have incorporated health

as a right in their constitutions. In India, health is included in the directive principles of

state policy but it is not a part of the fundamental rights in Indian Constitution (WHO

report on 'Right to Health' 2011). Although the directive principles direct the actions of

the government but the major difference between Fundamental right and directive

principles is the enforcement in a court of law. Unlike Fundamental Rights, directive

4
principles are not enforceable by law. Unless the 'health' becomes a fundamental right

the citizens of a country cannot hold the state accountable for healthcare delivery.

The World Health Assembly also endorsed the member countries to make

suitable national policies and plans to achieve this target. It also gave guidelines to the

member states so as to develop National Health Policies. The WHO reviewed the

improvements in the health status of the member countries and realised that the

'Health for All' goal was not possible to achieve by 2000. In 1998, World health

Assembly set another goal “Health for All in the 21st century which targets at

reducing the disease burden in the world and to bring the basic health services within

the reach of every human being (Ramachandrudu, 1997). However most low and

middle income nations are finding it a challenge to work on this target as 'Health for

All' cannot be achieved without increasing the public spending on health and the

misery is that India is one of the nations with very low public health spending

(Sathyamala&Kurian, 2008).

In 2005, all the WHO member states made a commitment to 'Universal Health

Coverage' to provide equitable access to healthcare to all regardless of gender, income

level and religion (The World Health Report, 2013). The setting up of this objective

led to greater emphasis on the health system by most of the countries. As a national

effort to achieve Universal Health Coverage in India, High Level Expert Group was

constituted by Planning Commission of India in 2010 (Reddy K, 2015). The group

analysed the existing healthcare system and made recommendations to direct the

existing health policies towards the objective of Universal Health Coverage. The

HLEG report drew attention towards various critical areas in the health sector which

5
need to be worked upon such as low public health spending, shortage of skilled health

personnel and infrastructure, unregulated private health sector.

Poverty is one of the important factors that lead to ill health (Grant, 2005). In

order to eliminate poverty and to improve the global health the United Nations in

2000 set Millennium Development Goals to be achieved by 2015. In total eight goals

were set, out of which the three health related goals include (1) Reduce Child

Mortality (2) Improve Maternal Health and (3) Combat HIV/AIDS, malaria and other

diseases. Although India has been successful in improving the child health and

eradicating diseases like polio, however, it has not yet been able to achieve the MDG

targets for maternal mortality.

In 1981, WHO developed a list of health indicators to measure the health

status of people across the world. These included Infant Mortality Rate, Maternal

Mortality Rate, Life Expectancy, availability and access to healthcare etc. The life

expectancy is the most popular and commonly used measure of the health status of the

population. Currently, the people of Japan have the highest life expectancy (84 years).

In spite of launching several health programmes India has not been able to improve

the life expectancy much. Unfortunately, it is one of the countries with lowest life

expectancy (66 years) and Indians live a shorter life than most of the Asians (Table

1.1). With the current economic growth, it is believed that India will soon catch up the

developed nations however it has to go a long way to increase life expectancy up to

their level.

6
1.3 Health Planning in India

The structured government initiatives are not new to the Indian health sector,

several steps were taken even prior to independence to improve the Indian Public

Health System. These efforts started with the formation of Bhore Committee in 1943.

The committee aimed at examining the existing health conditions in the country and

to make recommendations. On observing a poor state of health in the nation the

committee in its “Health Survey and Development Committee report” in 1946

recommended an integration of preventive and curative services at all administrative

levels (Duggal R, 2002). The committee proved to be a landmark in the public health

in India as it introduced the concept of three tier Indian health system namely,

primary, secondary and tertiary levels of care. It also shifted the focus of Indian health

sector to the eradication of several diseases like malaria, goitre, tuberculosis, leprosy

through the disease control programmes. The Committee through its report

emphasized on providing free universal health coverage to the whole nation. The

Indian Government has been regulating the health sector with five year plans and the

health committees until it came out with formal National health policy in 1983.

The First Five Year Plan (1951-56) clearly lays down the importance of

health: „nothing can be considered of higher importance than the health of the people

which is a measure of their energy and capacity as well as of the potential of man-

hour for productive work in relation to the total number of persons maintained by the

nation. For the efficiency of industry and agriculture, the health of the worker is an

essential consideration‟ (The First Five Year Plan draft, Planning Commission,
7
Government of India). As the incidence of epidemic diseases was one of the major

problems faced by the nation during that time, the plan focussed on controlling them.

ThetSecondtFivetYeartPlant(195661)tdidtnottmaketanytstructuraltchangesttotthetheal

thtcaretdeliverytsystem.tThe

thealthtprogrammestduringtthetsecondtfivetyeartplantaimedtattexpandingtthethealth

tinfrastructuretintorderttotimprovetthetavailabilitytoftthethealthtcaretservices t(GoIt

1956).tAlthoughtthetfirstttwotplanstbroughttabouttatlottoftdevelopmenttintthetfieldtof

thealth,tcertaintdeficienciestliketshortagetoftdoctors,tmedicaltinstitutionstetctstill

texistedtintthetIndianthealthtsystem.tIntspitetoftprovidingt'specialtattention'ttotthet

ruraltareastthrought'CommunitytDevelopmenttProgramme',tthesetproblemstcontinued

ttotprevailtintruraltregions.tThetMudaliartCommitteetsettuptint1959tobservedtatsharp

tdeclinetintthetmortalitytrates.tHowever,ttheytadmittedtthetshortagetoftbasicthealtht

servicestintthetcountry.tThetcommitteetrecommendedtthattinsteadtoftexpandingtthe

tpresentthealthtsystem,tthetexistingthealthtinstitutionstshouldtbetupgraded.tThetThirdt

FivetYeartPlant(1961-

66)tfocussedtontthetprevailingtshortagetofthealthtpersonnel.tItthighlightedtthetneed

tforttrainingtthetdoctorstforttheteffectivetfunctioningtoftthetexistingthealth

tinstitutions.tFamilytplanningtwastthettoptprioritytoftthetFourthtFivetYeartPlant(1969

-74).tIttrecommendedtthatttotreaptthetbenefitstofttheteconomictdevelopment,the

tpopulationtgrowthtratetshouldtbetcontrolled.tAparttfromtthis,tthetplantalsot

recognisedtthetneedttotimprovetthetfunctioningtoftPrimarytHealthtCentrestandtathuge

tamounttoftfundstweretallocatedtfortthistpurpose.

8
ThetFifthtPlant(197-478)treinforcedtthetintegrationtoftnutrition,tmaternalt&tchild

thealthtandtfamily

twelfaretservicest(GoIt1974).tThetregionaltdisparitiest(urbantandtruraltareas)tintthe

tavailabilitytoftthethealthtservicestweretalsotrecognisedtintthistplantandtittaimedtat

tincreasingtthetaccessttothealthtservicestintthetruraltareastthroughtMinimumtNeeds

tProgrammet(MNP).tInt1973tontthetrecommendationstoftKartartSinghtCommittee

tMulti-

PurposetWorkerst(MPW)tprogrammetwastlaunchedtundertwhichtthetexistingthealth

tworkerstwerettrainedtfortmultiplettaskstsotasttotintegratetthemtintotthetruralthealth

tstructure.tThetGovernmenttoftIndiatintroducedtCommunitytHealthtWorkerstschemetto

ttrainthealthtworkerstundertthetsupervisiontoftMPW.tEventaftertnumeroustattemptstmade

tbytthetprevioustplansttoteliminatettheturbantruralthealthtdisparities,tthetsixth

tplant(1980-

admittedtthattthetactualtbenefittoftthetimprovementstintthethealthtservicestwas

tenjoyedtbyttheturbantareas.tInt1983,tIndiatformulatedtitstfirsttNationaltHealthtPolicy

tbasedtontthetguidelinestoftWHO'stdeclarationtoft“Healthtfortalltbyt2000”.tThetplantalso

proposedttotintensifytthetcommunicabletdiseasestcontroltprogrammetand

trecommendedttotintroducetnewtdrugsttotachievetthistobjective.

Thethealthtplanningtexperiencedtatshifttaftertthetsixthtplan.tThetsubsequentt

twotplanstfocussedtontopeningtthethealthtsectorttotthetprivatetplayers.tIntordertto

tachievetthetobjectivetoft'HealthtfortAll',tthistplantlaunchedtthetstrategytoft'Health

tfortthetUnderprivileged'.tThetNinthtFivetYeartPlant(1997-

2002)tagaintfocussedtontthetimprovementtoftprimarythealthcaretinfrastructuretandttot

checktthetrisingtpopulationtgrowthtratetbytpreparingtNationaltPopulationtPolicy,t

9
2000.tThistplantmadetseveralteffortsttotfilltthetgapstintthetmanpowertand

tinfrastructuretespeciallytattthetprimarythealthtcaretleveltsotasttotimprovetthethealtht

statustoftthetnation.tDuringtthetTenthtFivetYearPlant(2002-

07),tthetMinistrytoftHealthtandtFamilytWelfaretexaminedtthetdrawbackstoftNationalt

HealthtPolicy,t1983tandtthentintroducedthealthtpolicytwhichtwastnamedtastNationalt

HealthtPolicy,t2002.tThistpolicytattemptedttoteradicatetpoliotbyt2004,ttotachievet

zerotleveltgrowthtoftHIV/AIDStbyt2007,ttotreducetInfanttMortalitytRatettot30/1000t

byt2010,ttotincreasetusetoftpublicthealthtfacilitiesttotmoretthant75tpertcenttbyt2010t

andttotincreasetgovernmentthealthtexpendituretfromtthetcurrentt0.9tpertcentttot2t

pertcenttoftGrosstDomestictProductt(GDP)tbyt2010.tDuettotthetInternational

tMonetarytFundt(IMF)tandtWorldtBanktpressure,tusertfeetwastintroducedtintthet

governmentthospitalstduringtthistperiod.tAnothertmajortprogrammetwhichthast

provedttotbetatmilestonetintthetIndianthealthtsectortistthetoftNationaltRuraltHealtht

Missiont(NRHM)tint2005.

ThetEleventhtPlant(2007-

12)tpromotedtthetusetoftInformationtTechnologytinthealthcaretandtgovernance.tThet

concepttofte-

healthtwastinitiatedtandtHealthtManagementtInformationtSystemtwastalsotsettup

tduringtthistperiod.tAnothertattempttintthethealthtsectorttotimprovetthetaccessibilityt

ofthealthtservicestduringteleventhtplantwastthetoftRashtriyaSwasthyaBimaYojana

t(RSBY)tbytMinistrytoftLabourtandtEmployment,tGovernmenttoftIndiatint2008tby

tprovidingthealthtinsurancetcoverttotBelowtPovertytLinetpopulationtandtinformal

tsectortworkerstoftIndia.tThetobjectivetoftthetschemetisttotprotecttthesetfamilies

tfromtthetburdentofthugetouttoftpockettexpenditurestonthealthtbytimprovingtaccess

10
ttothealth

t(PresstInformationtBureau,tGovernmenttoftIndia).tBytinsuringtthethealthtoftthe

tpeople,tthistschemethastcreatedtdemandtforthealthtservicestintthetruraltregions

twhichtistactingtastantincentivetfortthetprivatetplayersttotsettupthospitalstintthetruralt

areastwhichtwilltresulttintimprovedtruralthealthtinfrastructure.tUndoubtedly,tRSBY

thastatlottoftpotentialtbuttitthasttotgotatlongtwayttothelptIndiatachievetthe

tMillenniumtDevelopmenttGoals.

ThetTwelfthtFivetYeartPlant(2012-

17)taimstattachievingtUniversaltHealthtCoveragetintthetcountrytwhereteach

tindividualtwillthavetaccessttotbasicthealthtservicestattreasonabletprices.tTotachievet

thistobjective,tthetGovernmenttoftIndiathastlaunchedtNationaltHealthtMission,

twhichtincludestthetalreadytexistingtNRHMtandtnewtNationalUrbantHealthtMission.

tThroughtthistmission,tthetGovernmenttoftIndiataimsttotfocustontthethealthtoftthe

turbantpoortalongtwithtthetruraltpopulation.tThistplantalsotfocusestontincreasingtthet

healthtsectortexpendituretbothtbytthetcentraltandtstatetgovernments.tThetHightLevelt

ExperttGroupt(HLEG)tformedttotachievetUniversaltHealthtCoveragetemphasizedtin

titstreporttthattthethealthtcaretservicestshouldtbetdeliveredtprimarilytbytthetpublic

thealthtsystem.tAlthoughtthet12thtfivetyeartplantattemptedttotincorporatetthetsuggest

ionstmadetbytHightLeveltExperttGroupttotachievetUniversaltHealthtCoveragetby

t2022,thowever,tmosttoftthetrecommendationstweretrejectedtduettotpressuretfromtthe

tprivatethealthtcaretproviderst(Bajpai,t2014).

1.4tNationaltHealthtProgrammestintIndia

11
 Sincetindependence,tthetGovernmenttoftIndiathasttakentvarioustinitiativestto

timprovetthethealthtoftthetpeople.tThetNationaltHealthtProgrammestaretantimportant

tparttoftsuchtmeasures.tThesetprogrammestfocustontcontrollingtthetcommunicablet&

tnontcommunicabletdiseases,timprovingtthetmaternaltandtchildthealthtandtstrengthen

ingtthetoverallthealthtsystem.tThetprogrammesthavetbeentalteredtfromttimettottime

ttotmeettthetchangingtneeds.tBesidestthesetprogrammes,tatnumbertofthealthtpoliciest

havetbeentframedtfromttimettottimettotaddresstthetmajorthealthtissues.tThetfirst

tNationaltHealthtPolicytoftIndiatwastframedtint1983.t

Thettwotmajorthealthtprogrammes,tnamely,tNationaltRuraltHealthtMission

tandtNationaltUrbantHealthtMissionthavetprovedttotbetatmilestonetintthethealtht

sectortintIndia.tThesetarethealthtsectortstrengtheningtprogrammestwhichtfocuston

timprovingtthetprovisiontofthealthtservicestthroughouttthetcountry.tNRHMtistbasical

lytantumbrellatapproachtundertwhichtmosttoftthetdiseasetcontrolthealthtprogrammest

aretintegrated.tThetdetailstoftthetformationtandtfunctioningtoftthesettwotprograms

taretastfollows.

 NationaltRuraltHealthtMission

Thetprincipletoft'Inversetcaretlaw'tproposedtbytJuliantTodortHart(1971)tis

thighlytapplicabletintIndia,taccordingttotwhichtthosetwithtthetgreatesttneedtforthealth

tcarethavetthetgreatesttdifficultytintaccessingthealthtservicestandtleasttlikelyttothavet

theirthealthtneedstmet.t(HarttJtTep,t2000tandtSentettal.,t2002).tThististclearlyt

indicatedtbytthethugetruralturbantdisparitiestintthetprovisiontofthealthtcaretservices.t

ThetGovernmenttoftIndiatlaunchedtNationaltRuraltHealthtMissiontintAprilt2005,tast

arecommendationtoftmidtermtappraisaltoftthettenthtplan,ttotreducetthethealtht

12
inequitiestbytincreasingtfocustontthetruraltareastoftIndiat(DhillontS,t2011).tThe

tprimarythealthtservicestaretprovidedtintthetruraltareastthroughtatthreet-

tierthealthcaretsystemtastshowntintFiguret1.1.tThetmissiontaimstattimprovingtthe

tavailabilitytandtaccessibilitytofthealthtservicestintIndiatwithtspecialtfocustont18

tstatestwithtverytweakthealthtindicators,tnamely,ArunachaltPradesh,tAssam,tBihar,tC

hhattisgarh,tHimachaltPradesh,tJharkhand,tJammutandtKashmir,tManipur,tMizoram,t

Meghalaya,tMadhyatPradesh,tNagaland,tOrissa,tRajasthan,tSikkim,tTripura,tUttaranc

haltandtUttartPradesh.tPunjabtbeingtatrichertstatetistatlowtfocuststatetbuttthetfundstre

ceivedtfromtNRHMtaretstilltseveralttimestthetleveltoftthetstatestownthealtht

minitstorytbudget.

NRHMtoperatestattthreetlevelstwhichtaretnational,tstatetandtdistrict.tHealth

tmissionstaretdevelopedtseparatelytforteachtlevel.tThetfundstundertthetNRHMtaret

disbursedtviatthetsametroute.tThetfundstflowtfromtthetfederaltNRHMtpoolttotstate

thealthtsocieties,tthentstatethealthtsocietiestdistributetthetfundstamongtdistrictthealtht

societiestwhichtfurthertspendtthetfundstontblocktandtvillagethealth.tThetmainttargett

oftthetmissiontwasttotcreatetatcommunitytownedtdecentralisedthealthtdelivery

tsystemtwithtatfocustontimprovingtthetdeterminantstofthealthtliketwater,tsanitation,

teducation,tnutrition,tsocialtandtgendertinequality.tTotprovidetuniversaltaccesstto

tquality

thealthcarettotthetpeople,tNRHMtpromotestthetpartnershipstbetweentcentral,tstate

tandtlocaltgovernments,tandtcommunitytparticipationtintthetmanagementtoftprimaryt

healthtprogrammes.tIttalsotencouragestthetstatestandtthetcommunityttottaketlocal

tinitiativestintimprovingthealthcare.tUndertNRHM,tthetcommunitytparticipationtis

tachievedtbytsettingtuptvarioustcommitteestliketVillagethealthtandtsanitationtcommit

13
tee,tRogiKalyanSamitist(RKS)tandtASHAst(AccreditedtSocialtHealthtActivists).tRK

StaretconstitutedtattCommunitytHealthtCentrestandtPrimarytHealthtCentrestlevelsttot

managetthethospitaltactivitiestandtthetASHAstaretthetfemalethealthtactiviststselectedt

forteverytvillagetwhichtactstastthetinterfacetbetweentthetcommunitytandtthetpublic

thealthtsystemt(NRHM,t2005-12).

14
 Chaptert-2t

INDICATORStOFtHEALTH

Astcriticstoftpopulationthealthtstatustassessmentsthavetcorrectlytnotedtthattthetindicators

tusedtdescribetdiseasetandtdeathtrathertthanthealth.tInttheirtview,tthesetindicatorstaretmore

tappropriatetfortcommunitiestwithtathightmortalitytratetintyoungertyearstandtat

correspondingtshortertlifetexpectancytastwelltastfortthetinfectioustdiseaseteratoftdayst past.t

Thetbottom

tlinetfortthesetcriticstistthattthesetindicatorstdotnottprovidetatsufficienttbasetforteffectivelyt

assessingtpopulationthealthtstatustandtdeterminingtpublicthealthtprioritiestintmanytcountries,

tincludingtmosttCaribbeantcountries,twithtchronictdiseasetpatternstandtlongtlifetexpectancy.t

Thetquestiontistnottsotmuchtwhethertatpersontlivedtortdiedtaftertexperiencingtathealthtevent

.tRather,tthetquestiontshouldtbethowtdoestonetavoidtbeingtattrisktfortadversethealthtevents,t

andthowtmuchtdisabilitytistpresenttintatpopulationtlivingtintanteratwheretchronictdiseaset

predominates.tTheretistthereforetatneedtfortnewtindicatorstthattincludetqualitytoftlifetand

atmeasuretoftthetnumbertofthealthytyearstlivedt–trathertthantjusttyearstlived.t

Newtindicatorstaretbeingtdevelopedttotreflectthealthtstatus,tprovidingtatvaluablettooltfor

thealthtplannerstandtpractitioners.tExamplestoftnewtindicatorstinclude:t

 health-adjustedtlifetexpectancyt(HALE)

 disability-freetlifetexpectancy

 healthytlifetexpectancy

 activetlifetexpectancy

 lifetexpectancytintgoodtperceivedthealth

 HealthytLifetYearst(Healys)t

15
Effortstaretbeingtmadetintatnumbertoftsectorsttotoperationalizetindicatorstsuchtastthese.tAst

well,ttheretistatmovettotcombinethealth,teducationtandteconomictindicatorstastindexesttot

providetatmoretcomprehensivethealthtstatustassessmenttoftpopulationsttotfittthetneedstof

ttoday.t

Healthstistatparticularlytinterestingtmeasure.tIttistatcompositetindicatortthattincorporatest

mortalitytandtmorbiditytintatsingletnumbert(Last,t2001,tp.t84).tProposedtastatbettertmeasure

tthantdisability-adjustedtlifetyears,tHealystincorporatestthetfollowingttypestoftindicators:t

 Incidencetandtaveragetagetattonset

 Extenttoftdisability

 Expectationtoftlifetattonse

16
CHAPTERt–t3

REVIEWtOFtLITERATURE

DuraisamytandtMahalt(2005)tinttheirtstudytexaminedtthetrelationshiptbetweentvarious

thealthtindicatorstandttheteconomictstatustoftthetpeople.tThetanalysistwastdonetusing

tpaneltdatatfort14tstatestfromtthetyeart1970-71ttot2000-

01.tThetassociationtbetweentthetLifetExpectancytattbirtht(LEB),tInfanttMortalitytRate

t(IMR)tandtothertindicatorstwastcalculatedtwithtthetpertcapitatNettStatetDomestic

tProductt(NSDP).tThetresultstrevealedtatpositivetcorrelationtbetweentthetLEBtand tper

tcapitatincome.tThetresearcherstestablishedtthattattwotwaytrelationshiptbetweentthese

tfactorsti.etbetterthealthtleadsttothighertpertcapitatincometandthighertincometleadstto

tbetterthealth.tOntthetcontrary,tatnegativetrelationtwastfoundtbetweentpovertytandtLEB.t

ThetIMRtwastfoundttotbetnegativelytrelatedtwithtthetpertcapitatNSDPtastthetIMRt

increasedtwithtdecreasedtincometlevel.tThetstudytalsotrevealedtthattthetstatetwithtgreater

tgrowthtintthetthreetdecadesthadtmoretimprovementtintthetLEB.tMoreover,tthetpublic

texpendituretonthealthtwastfoundttothavetatdirecttimpacttontthethealthtindicators.tTher

fore,tittwastsuggestedtthatttotincreasetthetpacetofteconomictdevelopment,tathighertlevelt

oftinvestmenttonthealthtsectortistrequired.

Hammertettal.t(2007)texaminedtthetconditiontoftgovernmenttandtprivatethealthtsector

tintIndia.tThetreasonstfortthetfailuretoftgovernmentthealthtservicestweretbroughttto

tlighttintthetstudy.tThethealthtsectortissuestweretdiscussedtbytdividingtthethealthtservice

stintottwotcategories,tnamely,t(1)tPreventivetandtpromotivetandt(2)tCurativethealthtcare.

tIttwastfoundtthattthetcommunicabletdiseasestweretmostlytprevalenttintthetpoortpeople

tbuttthetprogrammestlaunchedttotcontroltthesetdiseasestweretfocusingtontbothtpoortand

17
trichtequally.tIntcasetoftcurativetservicestthetmajortissuestwhichtweretfoundtintthe

tPrimarythealthtcentrestweretthetshortagetofthospitaltstaff,tthetabsencetofthealthtworkers

tfromthealthtfacility,tincompetenttandtuntrainedtstafftandtlacktoftcourtesyttowardstthe

tpatients.tThetlacktoftaccountabilitytwastfoundttotbetthetmajortfactortfortfailuretoftthe

tgovernmentthealthtservices.tIttwastsuggestedtthattthetpolicytmakerstshouldttranslatetthet

needstoftthetpatientstintotpoliciestandtthethealthcaretproviderstshouldtbetgiventincentive

sttotprovidetbetterthealthtservices.

Bhatt(1993)tanalysedtthetgrowthtoftthetprivatethealthtsectortandtestimatedtthetpossible

tfuturetimpactstoftthistgrowth.tVarioustreportstpublishedtbytCentraltBureautoftHealthtInt

elligencetweretusedtastthetdatatsource.tIttwastfoundtthattouttoftthettotalthealthtcare

tresources,tatlargetsharetwastspenttintthetprivatethealthtsector.tThetresearcherthighlighte

dtthetimportancetoftinvestingtontthethealthtresearchtandttechnologytastitthasta tdirect

timpacttontthetqualitytandtcosttofthealthtservices.tThethugetexpendituretmadetont

improperttechnologiestultimatelythadtatnegativetimpacttontthetpatientstintthetformtof

thealthtrisktandtthethightcosttofttreatment.tThetformationtoftatgovernmenttbodytto

monitortthetinvestmenttontthetinnovationstintthetfieldtoftheathtcaretresearchtwastsuggest

ed.tIttwastrecommendedtthattfinancialtincentivestshouldtbetgiventintorderttotovercome

tthetruralturbantdisparitiestintthetavailabilitytofthealthtinfrastructuretandtdoctors.tThe

tabilitytoftprivatethealthcaretprovidersttotprovidetpreventivethealthcaretalongtwithtthe

tcurativethealthtcaretwastbroughtttotlight.

Bhatt(1996)tmeasuredtthetawarenesstoftthethealthcaretproviderstabouttthe

timplementationtoftConsumertProtectiontActt(COPRA)tintthethealthtsector.tAtsampletof

t130tprivatethealthtcaretproviderstwastselectedtfromtthetcitytoftAhmedabad,tIndia.tThe

tdatatweretcollectedtwithtthethelptoftatquestionnaire.tThetresultstshowedtthattthetdoctors

18
tweretmoretawaretoftCOPRAtastcomparedttotthetothertregulatorytactstintthetfields

tofhealth.tAlthoughtthetmajoritytoftthetdoctorstbelievedtthattthetrulestandtregulation

strelatedttotprivatethealthtsectortsafeguardtthetinteresttoftthetpatientstbutttheytwere

tdoubtfultaboutttheirtimplementation.tIttwastindicatedtthattthetimplementationtof

tCOPRAtcouldtalsotacttagainsttthetinteresttoftthetpatientstastittmighttleadttotincreasetint

doctor'stfee,tdiagnostictcoststandtmoretprescriptiontoftmedicines.tAnothertissuetwhich

thadtbeentbroughtttotlighttintthetstudytwastknowledgetandtfinancialtresourcestrequired

ttotfiletatcomplainttintconsumertcourtstwhichtpreventstpatientstfromtusingtconsumer

trights.

Qadeert(2000)tdiscussedtthethealthtsectortreformstintIndia.tThetstudytlaidtdowntthattthe

ttransitiontintIndianthealthtsectortwastthetresulttoftthetpressuretfromtInternational

tMonetarytFundtandtWorldtBanktontIndiattotadopttStructuraltAdjustmenttPolicies.tIt

twastfoundtthattthethealthtreformstbroughtttwottypestoftchangest(1)tDeclinetintthe

tgovernmenttallocationsttotthethealthtsectortandt(2)tIncreasedtgrowthtoftthetprivate

thealthtsector.tThethealthtcaretinfrastructuretandtthetresearchtwhichtwastbeingtdonetby

tIndiantCounciltoftMedicaltResearchtsufferedtbadlytduettotthetreducedtpublicthealth

tspending.tThetresearchertcriticisedtthetIndianthealthtsectortfortfocusingtontthetupper

teconomictstratatthroughtgrowthtoftcorporatethospitalstandtignoringtthetpoor.tIttwast

suggestedtthattintorderttotovercometthistissuetdecentralisationtshouldtbetdonetinthealth

tsectortwhereintthetpowerstshouldtbettransferredttotthetlocaltgovernmentstort

PanchayatitRajtInstitutions.tThetincreasetintthetgovernmentthealthtexpendituretwast

recommendedtupttot2-3tpertcenttoftGDP.

BhattandtJaint(2004)tassessedtthetleveltoftgovernmentthealthtexpendituretmadetbytthet

statestandtitstrelationtwithtincometofteachtstate.tThetdatatwastextractedtfort14tstates

19
tfromtvarioustreportstpublishedtbytthetgovernment.tThettimetseriestanalysistoftdatatwast

madetandtthetresultstrevealedtthattthetpercentagetincreasetintthetGrosstState tDomestic

tProducttwastquitethightastcomparedttotthetincreasetintstatethealthtexpenditure.tOntan

taverage,teachtstatetwastfoundttotbetspendingtonlyt0.43tpertcenttoftGSDPtontpublict

health.tIntthetabsencetoftadequatetfinancialtresourcestintthetgovernmentthealthtsector,t

thetpeoplethavetstartedtpreferringtthetprivatethealthcaretservices.tIttwastindicated

tthetnationaltgoaltoftincreasingtpublicthealthtexpenditurettot2-

3tpertcenttoftGDPtwastdifficultttotachievetwithouttthetrisetinthealthtallocationstbytstates.

tThetneedtoftincreasingtthethealthtexpendituretandtutilisingtittefficientlytwasthighlighted

.tAparttfromtthis,tthetmuchtneededthealthtreformstweretalsotsuggestedtbothtintthetpublic

tandtprivatethealthtsector.

Qadeert(2007)treviewedtthetscenariotofthealthtservicestintIndia.tThetstudytrevealedtthat

tmajoritytoftthethealthcaretwastprovidedtbytthetprivatethealthtsectortwithtalmosttdoublet

healthtinstitutionstthantthattoftthetgovernmenttsector.tThetruralturbantdisparitiestintthe

tavailabilitytofthealthtfacilitiestweretalsothighlighted.tThetpublicthealthtinstitutionstin

tthe

truraltareastweretfacingtathugetshortagetoftthethealthtpersonneltincludingtdoctors,tnurses

,tandtsurgeons.tThethealthtindicatorstshowedtatdismaltpicturetoftthetIndianthealthtsectort

withtthetinfanttmortalitytratetandtmaternaltmortalitytratetmuchthighertthantexpected.tItt

wastobservedtthattintthetabsencetoftpropertgovernmentthealthtfacilities,tthetmiddletclasst

pressurisedtthetgovernmentttotallowtthetprivatetplayersttotentertthethealthtsector.tThe

tstudytfoundtthattthethealthtreformstbroughttaftertadoptingtStructuraltAdjustmentt

Policiest(SAP)talsotfailedttotimprovetthethealthtservices.tPeopletweretfoundttotbetmore

tinclinedttowardstthetprivatethealthtservicestasttheytconsideredthemttotbetmoretefficient.

20
tIttwastobservedtthattthetnon-

treatmenttcasestweretincreasingtamongtthetpoortpeopletduettottheirtinabilityttotpaytthe

texorbitanttpricetchargedtbytthetprivatetsector.tThetauthortsuggestedtthattthetpublic

thealthtinvestmenttshouldtbetincreasedtandtthetregulationtmechanismtshouldtbe

tdevelopedtfortthetprivatethealthtsector

Nongkynrihtettal.t(2004)texaminedtthetsuccesstofttwotmajorthealthtprogrammesttot

controltthetcommunicabletdiseases,tnamely,tNationaltLeprosytEradicationtProgramme

t(NLEP)tandtNationaltAnti-

MalariatProgrammet(NAMP).tIttalsotaimedttotanalysetthettrendtintthetincidencetoft

lifestyletdiseases.tThetanalysistwastdonetontthetbasistoftvariousthealthtreportstpublishedt

bytthetMinistrytoftHealthtandtFamilytWelfare.tThetresultstrevealedtthattthetNLEPthas

tbeentquitetsuccessfultintbringingtatreductiontintthetleprosytcases.tAlthoughtthetNAMPt

hastplayedtatsignificanttroletintthetcontroltoftMalariatbuttthetdiseasethastnottyettbeen

teliminated.tThetstudytsuggestedtthattittcouldtbetpossibletonlytbyttakingtpropert

sanitationtmeasures.tDuettotthetshifttintthetlifestyletoftthetpeopletoftIndia,ttheythavet

becometmoretexposedttotthetnon-

communicabletdiseasestliketDiabetestandtCancer.tIttwastsuggestedtthattstrongtpoliticalt

willtistrequiredttotfighttwithtexistingtdiseasestandtothertissuestintthetIndianthealthtsector

Kaushiktettal.t(2008)tassessedtthetrelationtbetweentthettypetoftmedicalteducationttakent

bytphysicianstintIndiatandttheirtmigrationttotforeigntcountries.tThetdatatregarding

tthetnumbertoftdoctorsttakingtmedicalttrainingtwastassembledtfromtthetwebsitestoftIndia

ntmedicaltcollegestandtatdatabasetfortyearstbetweent1955tandt2002twastcreated.tThe

tphysiciantregistertoftAmericantMedicaltAssociationtwastalsotusedttotobtaintthetnumbert

21
oftdoctorstwhotemigratedtfromtIndia.tThetqualitytoftmedicalttrainingtprovidedtby

tdifferenttcollegestwastmeasuredtontthetbasistoftindicatorstliketthetaccreditationtgrades

tgiventbytMedicaltCounciltoftIndia,tassessmenttbytstudents.tThetresultstshowedtthattthet

emigrationtratettotthetUStwasthightintcasetoftthettoptmosttmedicaltcollegestoftIndiatandt

ittwastlowertintcasetoftlowtrankedtcolleges.tSimilartresultstweretreportedtregarding

tmigrationtoftIndiantdoctorsttotthetUK.tThetlowtqualitytoftmedicalttrainingtintIndiatas

tcomparedttotdevelopedtcountriestliketUSAtandtUKthastbeentindicatedtastonetoftthet

reasonstforthightemigrationtrate.tThetresearchertfurthertfocusedtthattthetlosstofthealtht

manpowertcannottbetmettjusttbytincreasingtthetnumbertoftprivatetmedicaltcollegest

becausetverytfewtcollegesthavetadequatetfacilitiesttottraintandtdeveloptbestthealthtleader

stintthetcountry.

Ghosht(2010)texaminedtthetcorrelationtbetweenthightouttoftpockettexpendituretont

healthtandtincreasingtpoverty.tThetdatatwastextractedtfort16tstatestfromtthet50thtroundt

(1993-94)tandt61sttroundt(2004-

05)treportstoftNationaltSampletSurveytandtcomparisontwastmadetbetweenttwottime

tperiodstsotasttotmeasuretthetchangetintthetvariablestovertatdecade.tThetresultstshowed

tthatttheretwastatsharptincreasetintthetouttoftpockettexpendituretbetweenttwotdatatpoints.

tDuettotthetshortagetoftgovernmentthealthtinfrastructurettherethastbeentantincreasetintthe

tusetoftprivatethealthtservicestwhichthastfurthertresultedtintotgreatertOuttoftpocket

t(OOP)texpenditure.tHowevertnotabletvariationstweretobservedtregardingtthetchangetint

OOPtexpendituretbetweentthetstates.tThetstudytindicatedtthattthetnewtpoliciestwhicht

promotedtthetprivatetplayerstintthethealthtsectortledttotatsignificanttincreasetintthe

tpovertytlevelstoftthetnation.tAtgreatertpercentagetoftpeopletweretpushedtbelowtthe

tpovertytlinetduettotincreasedtOOPtpaymentstint2004-05tintmosttoftthetstates.t

22
Dupast(2011)tanalysedtthetscenariotofthealthtintthetdevelopingtcountriestoftthetworld.

tThetstudytrevealedtthetattributestofthealthtbehaviourtoftthetpeopletintlowtincome

tdevelopingtcountries.tIttwastfoundtthattthetpeopletintthesetcountriestspendtmoretont

curativethealthtcaretandttheirtinvestmenttintpreventivethealthtistverytlow.tThetresults

tshowedtthattintIndiatintspitetoftthethightOuttoftPockettexpenditure,tthetqualitytofthealth

tservicestbeingtprovidedttotthetpatientstwastverytpoor.tOnetoftthetreasonstfortlow

utilisationtoftpreventivethealthtcaretintthesetcountriestwastabsenteeismtofthealthtworkers

tfromtthetgovernmentthospitals.tThetresearcherthighlightedtthattthetpeopletlackt

informationtabouttthetmethodsttotpreventtillnesstandthugetmoneytsavingstwhichtcantbet

madetbyttakingtpreventivetsteps.tIttwastsuggestedtthattbesidestpropertinformation,

tsubsidisedtpricestandtfinancialtincentivestshouldtbetgiventtotthetpeoplettotincreasetthet

usetoftpreventivethealthtmeasures.tOntthetcontrary,tatsticktapproachtshouldtbetused

tundertwhichtcertainthealthtbehaviourtistmadetobligatory

23
 CHAPTERt–t4

OBJECTIVESt

&

RESEARCHtMETHODOLOGY

4.1tThetobjectivestoftthetpresenttstudytaretto:-

(i)texaminetthetmajortindicatorstofthealthtliketbirthtrate,tdeathtratetlifet

expectancytandtinfanttmortalitytrate,tetc.

(ii)tanalyzetthettrendstinthealthtcaretinfrastructuretliketnumbertofhospitals,

tdispensaries,tprimarythealthtcentres,tbedstetc.

(iii)texaminetthettrendstandtpatterntoftpublictexpendituretonthealth.

(iv)tanalyzetthetdistributiontofthealthtexpendituret(inter-sectortandinter-

classtanalysis).

(v)tstudytthetvarioustfactorstthattlimittthetabilitytoftthethealthsectorttot

improvetthethealthtoftthetpeople.

4.2tRESEARCHtMETHODOLOGYt

Researchtistonetoftthetmosttimportanttpartstoftanytstudytandtpertainsttotthe

tcollectiontoftinformationtandtknowledge.tMarketingtresearchtistdefinedtastthet

systematictdesign,tcollection,tanalysis,tandtreportingtoftdatatandtfindingstrelevantttot

atspecifictmarketingtsituationtfacingtthetcompany.tMytprojectthastbeentdevelopedton

thastbasistoftbothtexploratorytandtdescriptivetresearch.tThetresearchtprocesst

24
dependstupontdevelopingtthetmosttefficienttplantfortgatheringtthetneededtinformation

.tDesigningtatresearchtplantcallstfrotdecisionstontthetdatatsources,tresearchtapproach

es,tresearchtinstruments,tsamplingtpaln,tandtcontacttmethods.t

4.2.1tUniversetoftthetstudyt

ThetuniversetoftthetstudytincludestalltthetdoctorstworkingtintGovernmenttandtPrivate

thospitalstoftPunjabtandtthetin-

patientstgettingttreatmenttinteithertPrivatetortGovernmentthospitaltintPunjab.tThe

tjustificationtoftthetuniversetistthattPunjabthastbeentrankedtamongtthethighesttpert

capitatincometstatestfortlasttseveraltdecades.tMoreover,tthetPunjabthealthtsectorthast

experiencedtmajortreformstintthethealthtsectortwithtthetcreationtoftPunjabtHealtht

SystemtCorporationtintthetrecenttpast.tThetresponsetoftthetdoctorstandtin-

patientsthastbeenttakentfortachievingtthetobjectivestoftthetresearch.tFurther,tthetpatientst

whothadtbeentadmittedttotthethospitalstfortmoretthanttwotdaystweretincludedtintthe

tsample.t

4.2.2tDatatSourcet

Fortthistprojecttbothtprimarytandtsecondarytdatatweretvaluabletsourcestof

tinformation.t

Secondarytdata

Secondarytdatatprovidestatstartingtpointtfortanytresearchtandtofferstvaluabletsourcest

oftalreadytexistingtinformation.tSecondarytdatatarettheteasiestttotgathertandtthetcostt

oftcollectingtthistdatatistalsotverytlow.tFortmytprojecttworktittwastcollectedtthrought

25
thethelptoftvarioustdirectoriestoftvarioustassociations,tmagazines,tnewspapers,t

websitestetc.tThetdirectoriesthelpedtmetintshorttlisitngtpeople,tfortmyttargettpeople.t

Sometoftthetdirectoriestmadetusetoftaretastfollows:

 Telephonetdirectory

 Incomettaxtoffice

 Citytdirectory

 Charteredtaccountanttdirectory

 Carpettindustriestdirectory

 Indiantmedicaltassociationtdirectory

 Transportertdirectory

 Lawyerstdirectory

 Builderst&tconstructorstdirectories

26
 CHAPTERt–t5

HEALTHtSCENARIOt

INtPUNJAB

HealthcarethastbecometonetoftIndia’stlargesttsectorst-

tbothtinttermstoftrevenuetandtemployment.tHealthcaretcomprisesthospitals,tmedicaltdevices,

tclinicalttrials,toutsourcing,ttelemedicine,tmedicalttourism,thealthtinsurancetandtmedical

tequipment.tThetIndianthealthcaretsectortistgrowingtattatbrisktpacetduettotitststrengtheningt

coverage,tservicestandtincreasingtexpendituretbytpublictastwelltprivatetplayers.

Indianthealthcaretdeliverytsystemtistcategorisedtintottwotmajortcomponentst-

tpublictandtprivate.tThetGovernment,ti.e.tpublicthealthcaretsystemtcomprisestlimitedtsecond

arytandttertiarytcaretinstitutionstintkeytcitiestandtfocusestontprovidingtbasicthealthcaret

facilitiestintthetformtoftprimarythealthcaretcentrest(PHCs)tintruraltareas.tThetprivatetsectort

providestmajoritytoftsecondary,ttertiarytandtquaternarytcaretinstitutionstwithtatmajort

concentrationtintmetros,ttiertItandttiertIItcities.

India'stcompetitivetadvantagetliestintitstlargetpooltoftwell-

trainedtmedicaltprofessionals.tIndiatistalsotcosttcompetitivetcomparedttotitstpeerstintAsia

tandtWesterntcountries.tThetcosttoftsurgerytintIndiatistabouttone-

tenthtoftthattintthetUStortWesterntEurope.

5.1tMarkettSize

ThethealthcaretmarkettcantincreasetthreetfoldttotRst8.6ttrilliont(US$t133.44tbillion)tbyt2022

27
Indiatistexperiencingt22-

25tpertcenttgrowthtintmedicalttourismtandtthetindustrytistexpectedttotdoubletitstsizetfrom

tpresentt(Aprilt2017)tUS$t3tbillionttotUS$t6tbilliontbyt2018.

Theretistatsignificanttscopetfortenhancingthealthcaretservicestconsideringtthatthealthcaret

spendingtastatpercentagetoftGrosstDomestictProductt(GDP)tistrising.tThetgovernment’s

texpendituretontthethealthtsectorthastgrownttot1.4tpertcenttintFY18Etfromt1.2tpertcenttint

FY14.tThetGovernmenttoftIndiatistplanningttotincreasetpublicthealthtspendingttot2.5tper

tcenttoftthetcountry'stGDPtbyt2025.

5.2tInvestment

ThethospitaltandtdiagnostictcenterstattractedtForeigntDirecttInvestmentt(FDI)tworthtUS$t6

tbilliontbetweentAprilt2000tandtDecembert2018,taccordingttotdatatreleasedtbytthetDepartme

nttoftIndustrialtPolicytandtPromotiont(DIPP).tSometoftthetrecenttinvestmentstintthetIndiant

healthcaretindustrytaretastfollows:

 HealthcaretsectortintIndiatwitnessedt23tdealstworthtUS$t679tmilliontintH12018.

 IndiatandtCubathavetsignedtatMemorandumtoftUnderstandingt(MoU)ttotincrease

tcooperationtintthetareastofthealthtandtmedicine,taccordingttotMinistrytoftHealthtand

tFamilytWelfare,tGovernmenttoftIndia.

 FortistHealthcarethastapprovedtthetde-

mergertoftitsthospitaltbusinesstwithtManipaltHospitaltEnterprises.tTPGtandtDr.t

RanjantPaltcouldtinvesttRs.t3,900tcroret(US$t602.41tmillion)tintManipaltHospitalt

Enterprise.

5.3tGovernmenttInitiatives

SometoftthetmajortinitiativesttakentbytthetGovernmenttoftIndiattotpromotetIndianthealthcare

tindustrytaretastfollows:
28
  OntSeptembert23,t2018,tGovernmenttoftIndiatlaunchedtPradhanMantritJantArogya

Yojanat(PMJAY),ttotprovidethealthtinsurancetworthtRst500,000t(US$t7,124.54)tto

tovert100tmilliontfamiliesteverytyear.

 IntAugustt2018,tthetGovernmenttoftIndiathastapprovedtAyushmantBharat-

NationaltHealthtProtectiontMissiontastatcentrallytSponsoredtSchemetcontributedtbyt

bothtcentertandtstatetgovernmenttattatratiotoft60:40tfortalltStates,t90:10tforthilly

tNorthtEasterntStatestandt60:40tfortUniontTerritoriestwithtlegislature.tThetcentertwil

ltcontributet100tpertcenttfortUniontTerritoriestwithouttlegislature.

 ThetGovernmenttoftIndiathastlaunchedtMissiontIndradhanushtwithtthetaimtof

timprovingtcoveragetoftimmunisationtintthetcountry.tIttaimsttotachievetatleastt90

tpertcenttimmunisationtcoveragetbytDecembert2018twhichtwilltcovertunvaccinatedt

andtpartiallytvaccinatedtchildrentintruraltandturbantareastoftIndia.

5.4tAchievements

Followingtaretthetachievementstoftthetgovernmenttintthetyeart2017:

 Int2017,tthetGovernmenttoftIndiatapprovedtNationaltNutritiontMissiont(NNM),ta

tjointtefforttoftMinistrytoftHealthtandtFamilytWelfaret(MoHFW)tandtthetMinistrytof

tWomentandtChildtdevelopmentt(WCD)ttowardstatlifetcycletapproachtfort

interruptingtthetintergenerationaltcycletoftundertnutrition.

 AstoftSeptembert23,t2018,tthetworld’stlargesttgovernmenttfundedthealthcaretscheme

,tAyushmantBharattwastlaunched.

 AstoftNovembert15,t2017,t4.45tmilliontpatientstweretbenefittedtfromtAffordablet

MedicinestandtReasonabletImplantstfortTreatmentt(AMRIT)tPharmacies.

 AstoftDecembert15,t2017,tthetGovernmenttoftIndiatapprovedtthetNationaltMedical

tCommissiontBillt2017,tittaimsttotpromotetareatoftmedicalteducationtreform.
29
5.5tRoadtAhead

Indiatistatlandtfulltoftopportunitiestfortplayerstintthetmedicaltdevicestindustry.tIndia’sthealth

caretindustrytistonetoftthetfastesttgrowingtsectorstandtittistexpectedttotreacht$280tbilliontbyt

2020.tThetcountrythastalsotbecometonetoftthetleadingtdestinationstforthigh-

endtdiagnostictservicestwithttremendoustcapitaltinvestmenttfortadvancedtdiagnostictfacilities

,tthustcateringttotatgreatertproportiontoftpopulation.tBesides,tIndiantmedicaltservice

tconsumersthavetbecometmoretconsciousttowardsttheirthealthcaretupkeep.

Indianthealthcaretsectortistmuchtdiversifiedtandtistfulltoftopportunitiestinteverytsegment

twhichtincludestproviders,tpayerstandtmedicalttechnology.tWithtthetincreasetintthet

competition,tbusinessestaretlookingttotexploretfortthetlatesttdynamicstandttrendstwhichtwillt

havetpositivetimpacttonttheirtbusiness.tThethospitaltindustrytintIndiatistforecastedtto

tincreasettotRst8.6ttrilliont(US$t132.84tbillion)tbytFY22tfromtRst4ttrilliont(US$t61.79t

billion)tintFY17tattatCAGRtoft16-17tpertcent.

India'stcompetitivetadvantagetalsotliestintthetincreasedtsuccesstratetoftIndiantcompaniestin

tgettingtAbbreviatedtNewtDrugtApplicationt(ANDA)tapprovals.tIndiatalsotofferstvast

topportunitiestintR&Dtastwelltastmedicalttourism.tTotsumtup,ttheretaretvasttopportunitiest

for tinvestmenttinthealthcaretinfrastructuretintbothturbantandtruraltIndia.

30
 PUNJABtHEALTHtSYSTEMStCORPORATIONt(PHSC)

Introductiont

ThetCorporationthastbeentincorporatedtthroughtlegislativetmeasurestbytthetstatetGovt.toft

Punjabttotbringtmoretadministrativetflexibilitytfortimplementationtoftthet''SecondtStatet

HealthtSystemstDevelopmenttProject"twithtWorldtBanktassistancettotupgradetHealth

tServicestattsecondarytlevel.tThetCorporationthasttakentovert150tInstitutionstwhichtincludes

tDistricttHospitals,tSub-

DivisionaltHospitalstandtCommunitytHealthtCentres.tThet86tMedicaltInstitutionstare

tsituatedtintruraltareastandt64taretintUrbantareas.

FunctionstoftthetCorporation

tThetfunctionstoftthetCorporationtshalltbetastfollows,tnamely:-

a)ttotformulatetandtimplementtthetschemestfortthetcomprehensivetdevelopmenttoftthe

tdispensariestandthospitals;

b)ttotconstructtandtmaintaintdispensariestandthospitalstandtmaintenancetoftcleanliness

ttherein;

c)ttotimplementtNationaltHealthtProgramstastpertthetdirectionstoftthetState.tThetState

tGovernmenttandtCentraltGovernmenttshalltmaketavailabletfundstfortthistpurpose;

d)ttotpurchase,tmaintaintandtallocatetqualitytequipmentttotvarioustdispensariestandthospital;

e)tTotprocuret,tstocktandtdistributetdrugs,tdiett,tlinentandtothertconsumabletamongtthe

tdispensariestandthospital;

f)ttotprovidetservicestoftspecialiststandtsuper-specialisttintvariousthospitals;

31
g)ttotentertintotcollaborationtfortsupertspecialtiestwiththealthtinstitutionstbothtwithintthe

tcountrytortabroadttotprovidetbettertmedicaltcare;

h)ttotreceivetdonations,tfundstandtthetliketfromtthetgeneraltpublictandtinstitutionstfromtboth

twithintandtoutsidetIndia;

i)ttotreceivetgrantstortcontributionstwhichtmaytbetmadetbytthetGovernmenttontsucht

conditionstastittmaytimpose;

j)ttotprovidetfortconstructiontofthousesttotthetemployeestoftthetdispensariestandthospital

,tandtthetmaintenancetthereoftbytmobilizingtresourcestfortfinancingtinstitutions;

k)ttotplan,tconstructtandtmaintaintcommercialtcomplexes,tpayingtwardstandtprovidingt

diagnostictservicestandttreatmenttontpaymenttbasistandttotutilizetthetreceiptstfortthe

timprovementtoftthethospitaltandtdispensariest;

l)ttotruntpublictutilitytservicetandtundertaketanytothertactivitytoftcommercialtnaturetfortthet

deliverytofthealthtcaretwithintortwithouttthethospitaltpremisestdirectlytortintcollaboration

twithtprivatetortvoluntarytagencytontcontractstbasist;

m)ttotengagetspecializedtagenciestortindividualstintthetrelevanttdisciplines,tdirectlytortfromt

externaltsourcestfortthetefficienttandtexpeditionstconducttoftanytoftthetfunctionstdetailed

tabove;tand

n)ttotprovidetimmediatettreatmenttintcasetoftemergencytandtfortunaccompaniedtpatients.

Punjab,tknowntastIndia'stgranary,thadtbeentthetfastesttgrowingtstatetoftIndiattilltthet

1990s.tThetcompoundtannualtgrowthtratetoftGrosstStatetDomestictProducttoftPunjab

twast7.88tpertcenttint1985-

86tastcomparedttot4.08tpertcenttgrowthtintGrosstDomestictProducttoftIndiat(Sawhney

32
,t2011).tAccordingttotNationaltHumantDevelopmenttReportt(2001),tPunjabtranked

tsecondtnexttonlyttotKeralatinttermstoftHumantDevelopmenttIndext(HDI)twithtlowest

tpovertytrate.tHowever,tthetspeedtoftgrowthtoftthetstatetstartedtdecliningtduringtthet

1990stduettotseveraltreasons,tparticularlytterrorism.tAstatresult,tthetpertcapitatincometoft

thetstatetbecametlowertthantothertmajortIndiantstates.tIntthet1980s,tPunjabtrankedtfirst

tinttermstoftpertcapitatNettStatetDomestictProductt(NSDP)tandtint2013-

14titstranktwast14th.tPunjabtnowtrankst5thtinttermstoftHDIt(IndiantHuman

tDevelopmenttReportt2011).tAlthoughtit'stpertcapitatincometiststilltmoretthantthe

tmajoritytoftthetstatestoftthetcountrytbuttittistalsotonetoftthetmosttdebttburdenedtstatetoft

India.tThetPunjabtgovernmenttborrowstfortpayingtofftthetsalaries,tpensionstandtfort

providingtsubsidies.

Thetfinancialtcrisistoftthetstatethastaffectedtpublictspendingtinteverytsectortespecially

tthethealthtsector.tThetfundstallocatedtfortthetdevelopmenttoftpublicthealthtservices tgo

tstagnatedtduringtthet1990s.tThetpublicthealthtexpendituretintPunjabt(astatpercentagetoft

totaltbudgettexpenditure)thastcontinuouslytdecreasedtovertthetlasttthreetdecadestfromt

nearlyt10tpertcenttint1980-81ttot5.21tpertcenttint2014-

15.tThetlowtgovernmentthealthtexpendituretattthetstatetlevelsthastledttotthetdeterioration

toftthethealthtservices.tHowever,tthethealthtservicestintPunjabthavetalwaystformedtan

tessentialtcomponenttoftitstfivetyeartplans.tPunjabtliketalltothertstatestgivestprioritytto

thealthtpoliciestoftthetcentraltgovernment,thence,tthethealthtobjectivestintthetfivetyear

tplanstoftPunjabtgovernmentthavetalwaystbeentinfluencedtbytthetnationaltfivetyeart

plans.

ThetPunjabtgovernmenttfollowingtthetdirectionstoftthetcentraltgovernmenttendeavouredt

totmeettthethealthtneedstoftthetstatetintthetfirsttthreetplans.tEventaftertthesetattempts,tthe

33
tgovernmenttcouldtnottprovidetadequatethealthtservicestduettothightgrowthratetoft

population.tHugetintertdistricttdisparitiestweretalsotobservedtastthethealthtinfrastructuret

wastconcentratedtintthreetdistricts,tnamely,tAmritsar,tLudhianatandtGurdaspur.tTherefor

e,tthetFourthtplantaimedtattexpandingtthethealthtservicestintthetlaggingtdistrictst

especiallytintthetruraltareas.tBesidestthis,tthetfamilytplanningtprogrammestweretgiven

timportancettotcontroltthetgrowingtpopulation.tDuringtthetFifthtplan,tthetdevelopmenttof

thealthtinfrastructuretwastthetmajortgoal.tIntorderttotachievetthis,tthetplantproposedtto

tsettuptnewtdispensaries,tdentaltclinictandttotupgradetthetexistingtPrimarythealthtcentrest

(HumantDevelopmenttReporttoftPunjab,t2004).

ThetSixthtplantobservedtthatttheretweretantadequatetnumbertoftmedicaltinstitutionstin

tthetstatetbuttthesetweretnottworkingtproperlytduettotthetabsencetofthealthtmanpower

tandtupttotdatetequipment.tSotintthistplan,tthetfocustwastshiftedtfromtexpansiontoft

infrastructurettotitstefficienttfunctioning.tSimilarly,tthetSeventhtplantproposedttotspendt

ontthettransformationtoftthetexistingtequipmenttintthetmedicaltinstitutions.tThethealthtin

frastructuretandtworkforcetweretthetprimetconcerntoftthetEighthtandtthetNinthtplan.tInt

thesetplans,tthetgovernmenttemphasizedtthetneedttotfiguretouttthetfactorstresponsibletfor

tthetpoorthealthtconditionstintthetstate.tLiketthetearliertplans,tthetTenthtplantfocusedtont

strengtheningtthetexistingtmedicaltinfrastructuretprovidingtAllopathic,tHomeopathictandt

Ayurvedicthealthtservices.tTheteffecttoftthetlaunchtoftNationaltRuraltHealthtMissiontbyt

thetcentraltgovernmenttint2005twastfelttintthetEleventhtplantoftPunjab.tAstatresult,tin

tthistplan,tthetPunjabtgovernmenttaimedtattimprovingtthetruralthealthtintthetstate.tFor

tthistpurpose,tittwastproposedttotincreasetcommunitytparticipationtbytforming

tRogKalyaniSamitistattthetvillagetlevels.

34
Thetmosttrecenttplanti.e.tthetTwelfthtplantaimsttotimprovetthetinfrastructuretand

teducationaltfacilitiestintthetmedicaltcolleges.tIttalsotproposesttotstarttprogrammesttot

traintthetmedicaltandtpara-

medicaltstaffttotimprovettheirtskillst(DrafttTwelfthtfivetyeartplan,t2007-

12).tAlthoughtintthetrecenttplansttherethastbeentantincreasetintthethealthtexpenditure

tintabsolutettermstbuttitthastbeentspenttmostlytontthetcurativethealthtservices.tThetstatet

governmenttliketthetcentraltgovernmentthastnottgiventduetimportancettotthetpreventive

thealthtcaretmeasuresttotchecktthetincidencetoftNontcommunicabletdiseasestliketdiabetes

,tCardiovasculartdiseasetandtcancer.tThetabsencetoftatregulatorytsystemtfortthetprivatet

healthtplayerstistyettanothertissuetintthethealthtsectortoftPunjab.

HealthtreformstintPunjab

Intthetbeginningtoft1990s,twhentthetIndianteconomytwastfacingtforeigntexchanget

reservetdeficit,tittadoptedtglobalisationttotgettfurthertloanstfromtthetWorldtBank.tWitht

thetviewttotachievetfasterteconomictdevelopment,tPrivatisationtandtLiberalisationtwere

tadoptedtthroughtIndianteconomictpolicy,t1991.tThetLiberalisation,tPrivatisationtand

tGlobalisationt(LPG)tpolicytprovedttotbetatmixedtblessingtfortthetIndianteconomy

tparticularlytthethealthtsectort(KaurtandtSinha,t2011).tOntonethand,tthettechnologicalt

advancementstimprovedtthethealthtcaretwhereastontthetotherthandtittledtto

tcommercializationtoftthethealthtservices.tIntthetposttliberalizationtperiod,tthet

governmenttallocationttotthethealthtsectortwastmarginalizedtattthetnationaltastwelltastthe

tstatetlevel.tAlthoughtthetPunjabtstatetgovernmenttdidtnottmaketanytplannedteffortstto

timprovetthethealthtscenariotbuttundertthetinfluencetoftthetnationalteconomictreforms,titt

tooktfewtinitiatives.tThetmainthealthtinitiativesttakenttotrestructuretthetPunjabthealth

systemtincludetthetformationtoftPunjabtHealthtSystemstCorporationst(PHSC)tint1995

35
,topeningtthethealthtsectorttotprivatetplayerstandtdecentralizationtofthealthtservicestatt

thetvillagetlevels.

PunjabtHealthtSystemtCorporationt(1996)

Thetsecondarytlevelthealthtcaretinstitutionstoccupytatverytimportanttpositiontintthe

tstatethealthtcaretsystem.tIntthetmidt1990s,tthetdistrictthospitals,tsubtdivisionalthospitalst

andtCommunitythealthtcentrestoftPunjabtweretintpitiabletconditiontduettotthetshortage

toftinfrastructure,tmanpowertandthealthtexpenditure.tTotovercometthis,tPunjabtstate

tgovernmenttrequestedtthetWorldtBankttotprovidetfinancialtaidttotimprovetthetaccesst

andtqualitytoftbasicthealthtservicestintthetstate.tAstatresult,tthetInternationa

tDevelopmenttAssociationt(IDA)tapprovedtcredittundertMulti-

StatetHealthtSystemtDevelopmenttProjectttotthreetstatestoftIndiatnamely,tPunjab,t

KarnatakatandtWesttBengalt(NationaltInstitutetoftHealthtandtFamilytWelfaretreporttont

PHSC,t2008).tThettotaltprojecttcosttintPunjabtwastestimatedtaroundtUS$106.1tmillion

touttoftwhichtUS$t89.7milliontwastsanctionedtbytIDAtandtresttoftUS$16.4tmilliontwast

mettbytthetPunjabtGovernment.tThus,tthetPunjabtHealthtSystemstCorporationt(PHSC)

twastincorporatedtbytthetStatetGovernmenttintthetyeart1996tthroughtthetenactmenttof

tLegislativetAct,t“ThetPunjabtHealthtSystemstCorporationtAct,t1996”t(PunjabtActtNo.6t

oft1996).tThetcorporationttooktovertaroundt166tmedicaltinstitutionstwhichtincludedt

districtthospitals,tsubtdivisionalthospitalstandtcommunityhealthtcentres.tIttistpertinentttot

mentiontthattIDAtagreedttotextendtfinancialtassistancetfortthethealthtsectortsubjectttotthe

tconditionstthattthetgovernmenttoftPunjabtwilltset-

uptatseparatetcorporationtintadditionttotthetexistingtdepartmentstofthealthtsectortin

tPunjab.tAttthetinitialtstagetgovernmenttresistedtthetproposaltbuttlatertontittsuccumbed

36
ttotthetpressuretoftthetWorldtBank.tSotultimatelytatparallelthealthtsystemtwastcreatedt

intthetformtoftcorporation.

ThetpurposetbehindtsettingtuptPHSCtwasttotimprovetthetsecondarytlevelthealthtservicest

intthetstatet(AggarwaltandtBansal,t2010).tBesidestthis,tthetPHSCtalsotaimedtattpropert

allocationtoftthethealthtresourcestintthetstatetbytdevelopingtsuitabletpolicies.tThetaccesst

andtqualitytoftthethealthtservicestweretalsotsoughtttotbetimprovedtsotasttotraisetthe

thealthtstatustoftthetpeople.tIntorderttotachievetthesetobjectives,tPHSCttooktthe

tfollowingtmajortinitiative.

IntroductiontoftHighertUsertCharges

UntiltthetformationtoftPHSC,tthetpatientstweretdividedtintotthreetclassestandtthepoorestt

(withtmonthlytincometlesstthantRs.t1000)tweretprovidedtfreetaccessttotthetbasicthealtht

services.tHowevertaftertthetinvolvementtoftWorldtBanktintPunjabthealthtsystemtthrough

tPHSC,tthetusertchargestweretincreasedtandtchargedtfromtalltthetpatientstexcepttthethold

erstoftthetyellowtcardt(Belowtpovertytlinetcard).tThetWorldtBank’stpolicyttotincrease

tthetusertchargestfromtthetpatientstprovedttotbetatfailuretastittincreasedtthetfinancialtbur

dentontthetpoortwithouttBPLtcardsttherebytmakingthealthtservicestouttofttheirtreach

t(Purohit,t2009).tTheretwastathugetdeclinetintthetutilisationtoftpublicthealthtservicest

aftertthetlevyingtoftusertcharges.tThetmajortdifferencetwastnoticedtintthetnumbertof

tinpatienttadmissionstintthetgovernmentthospitalstbeforetandtaftertthetintroductiontoftuse

rtcharges.

PHSCtstartedtatpolicytintwhichtthetusertchargestcollectedtfromtthetpatientstweret

retainedtbytthethospitals.tThetretainedtusertchargestweretusedtfortthetpurchasetoftdrugs,t

patienttfacilities,tequipmenttmaintenancetandtbuildingtmaintenance.tThetaimtbehindtthist

recommendationtwasttotfinancetthetexpansiontofthealthtservicestintthetstatetwithtthe
37
tcollectedtusertcharges.tThetconcepttoftthetyellowtcardtwastintroducedttotexempttthe

tpoortfromtthetusertcharges.tButtthetprocesstoftgettingtcardstandtrenewingtthemtafterta

tcertaintperiodtwastsottedioustthattverytfewtpeopletcouldtavailtthistexemption.tThe

tpolicytoftPHSCttotrecovertthethealthtexpendituretthroughtusertchargestworkedtnegativel

y.tEvenaftertchargingtthetusertfeetfromtthetpatients,tPHSCtcouldtrecovertonlyt0.7t

percenttoftthettotaltoutlaytoftthetprojectttillt1999t(VijayalakshmiEkkanath,t2006).t

AccordingttotatWorldtBanktreporttint2001,tthettotalthealthtexpendituretintPunjabtwastRs

.t17693tlakhstandtthetusertchargestreceiptstweretonlytRs.t1888tlakhs,ttherebytresulting

tintatverytlowtcosttrecoverytratiot(WorldtBanktReport,t2001).tTablet5.1tshowsttheteffect

toftPHSCtontthetdifferenttaspectstoftthethealthtsector.

38
tTabletno.5.2tTheteffecttoftPHSCtontdifferenttaspectstoftPunjabthealthtsector

Thetoccupancytafter Peopleteligibletfor
ThetpoortbeforetPHSC ThetpoortaftertPHSC
P H S Ce x e m p t i o n

Notchargestfortmost
Chargestfortnormaltchild
servicestiftmonthly 20tpertcenttreductiontin

deliverytexceedstRs. MemberstoftParliament
incometistlesstthantRs. hospitaltoccupancy
1 0 0 0
1000tpertmonth

Notchargetfortnormal 20-40tpertcenttreductiontin MemberstoftPunjab

Chargestfortatunittof
childtdelivery o u t p a t i e n t t c a s e s legislativetassembly
blood:tRst250

Notchargestfortatunittof EmployeestoftPunjab
Paytusertfeettotgetttreated
b l o o d t u s e d VidhanSabha

Verytfewtusertcardstwere

issuedtintPunjabtby AlltPunjabtgovernment

PHSCtduringtperiod e m p l o y e e s

i.e.1996ttot2002

Lacktoftawareness

amongtthetpoortabouttthe Yellowtcardtholders

yellowtcard

39
 Source:tInsaaftInternational'stReport,t2002tbytDrVineetatGupta

ThetsettingtuptoftPHSCtastatparalleltsystemtofthealthttotthetexistingtstatethealth

departmenttfurthertcontributedttotthetexistingtdisordertintthethealthtsystemtoftPunjab

t(Gupta,t2000).Thetexistingtproblemstoftcorruption,tpoortmanagementtandtfavouritism

tcontinuedtintPHSCtastittwastheadedtbytthetsametofficialstwhotweretmanagingtthe

tprevioustsystem.tContraryttotthetobjectivetoftincreasingthealthtfinancing,the

tgovernmenttallocationttotsecondarytlevelthealthtservicestdecreasedtfromt25tpertcentt

(ofttotalthealthtexpenditure)tint1994ttot19tpertcenttint2003t(Statethealthtsystemt

developmenttprojecttII:tWorldtbanktimplementationtreport,t2004).tThetDirectoratetof

tPublictEnterprisestandtDisinvestment,tPunjabtinttheirtpolicytfortdisinvestmentt(2002)t

recommendedtthetwindinguptoftPunjabtHealthtSystemtCorporationtduettotitstinabilityttot

improvetthethealthtscenariotoftPunjabtduringt7tyearstoftitstfunctioning.tOntthetother

thand,tthetWorldtBanktIItstatetdevelopmenttprojecttimplementationtreporttfoundtitttotbet

atsuccesstandtsuggestedtthetcontinuationtoftthetcorporation.tFinally,tthetstatustoftPHSCt

wastconvertedtfromtantautonomoustbodyttotatgovernmenttentitytundertDepartmenttoft

HealthtandtFamilytWelfare,tPunjabtfromt2002t(MulaytandtSharma,t2006).tSotthe

tattemptttotimprovetthethealthtservicestattthetsecondarytleveltledttotitstfurthert

deterioration.

PublictPrivatetPartnership

UndertthetinfluencetoftNationaltEconomictReformstandtthetformationtoftPHSCtint

Punjab,tthetstatetgovernmenttopenedtthethealthtsectorttotthetprivatetinvestment.tWithtthe

tobjectivetoftsettingtuptsupertspecialitytmedicaltinstitutions,tPunjabtUrban

tDevelopmenttAuthorityt(PUDA)tstartedtofferingtlandstattsubsidisedtratesttotthetprivatet

sectort(Bhatt,t2000).tIntreturn,tittwastexpectedtthattthesetprivatethospitalstwouldtprovide

40
tfreettreatmentttotbelowtpovertytlinetpeople-

tupttot10tpertcenttoftthetoutdoortandt5tpertcenttoftthetindoortpatients.tHowever,

taccordingttotatfieldtsurveytmajoritytoftthetpeopletweretunawaretabouttthistscheme

tundertwhichtthetyellowtcardtholderstweretexemptedtfromtthetusertfeetintprivatetsuper

tspecialitythospitalst(GhumantandtMehta,t2005)

OnetoftthetreasonstfortinadequatetaccessttotpublicthealthtcaretservicestintPunjabthas

tbeentthetshortagetofthealthtworkforcetfortclinicaltservicestliketdiagnosticstandtnon

tclinicaltservicesteg.tcleaning.tIntorderttotimprovetthetfunctioningtoftthethospitals,tittwas

tdecidedttotoutsourcetthesetservicesttotprivatetsector.tIntclinicaltservices,tthetoutsourcing

tistdonetfortAnaesthesia,tRadiology,tGynaecologist,tDentaltDoctors,tPhysiotherapist,

tRadiographers,tLab.tTechnicianstandtstafftNurses,tandtnontclinicaltservicestoutsourcing

tincludet(a)tAmbulancetservicestbythiringtdriverstontcontracttbasis,t(b)tSanitationt

servicestbythiringtsanitarytstafftontcontracttbasistandt(c)tElectrictandtplumbingtservices.

ThetIndianthealthtsectorthastmadetseveralteffortstoverttimettotbridgetthetgaptbetweent

thetdemandtandtsupplytoftthethealthtservices.tOnetoftsuchteffortstwastmadetintNationalt

HealthtPolicy,t2002.tIttrecommendedtthetusetoftpublictprivatetpartnershipsttotimprove

tthethealthtsectortbytcombiningtthetstrengthstoftbothtthetsectors.tOnetoftthetPublict

PrivatetPartnershipt(PPP)tinitiativestwastthetimplementationtoftRashtriyaSwasthyaBima

Yojnatwheretprivatethealthtinsurancetcompaniestweretalsotinvolvedtintmanagingtthet

scheme.tOntatparalleltbasistPunjabtgovernmentthastalsottakentvarioustPPPtinitiatives

twhichtincludetMohalitandtPatialatHospitalstintcollaborationtwithtMaxtHealthcare,t

PatialatMothertandtchildthospital,tNangaltGeneraltHospitaltandtNabhatCiviltHospital

.tThetmajortreasontfortinvitingtprivatetinvestmenttwastthetdeficienttgovernmenttfundst

whichtledttotincompletethospitaltconstructiontprojectstandtthetpoortfunctioningtoftthe

41
tcompletedtones.tThetmajortpublictprivatetpartnershipthealthtprojectstincludetthe

tfollowing:

 BhaiGhanhyaSehatSewatScheme

IttistatstatethealthtinsurancetschemetintroducedtintassociationtwithtICICILombardtfor

teconomicallytweakertsectionstoftthetsocietyt(memberstoftcooperativetsocieties).t216

trenownedthospitalstoftthetstatetliketFortis,tDMC,tPGItaretparttoftthistinitiativetandtprovidet

freettreatmentttotthetpatientstcoveredtundertthistscheme.tIntorderttotreducetfemaletfoeticide,t

atspecialtprovisionthastbeentmadettotissuetatgranttoftRs.t2100tontthetdeliverytoftatfemalet

child.

 PatialatMothertandtChildtHospital

PHSCtstartedtthetconstructiontoftthisthospitaltintOctobert2006tandtthetestimatedcosttoftthe

tprojecttwastRs.t7.78tcrores.tOuttoftwhicht2.6tcrorestweretspent,taftertwhichtthetSAD-

BJPtgovernmentttooktovertthetcharge.tThetnewtgovernmentthandedtovertthetprojecttto

tthetPunjabtInfrastructuretDevelopmenttBoardt(PIDB)tthroughtwhichtprivatetparticipationt

wastinvited.tThetcriticstaretoftthetviewtthatttheretaretseveraltmaternitythospitalstintthetcity,t

therefore,tthetamounttinvestedtintthetprojecttwastunnecessary.tDuettotthesetpoliticalt

contradictions,tthetconstructiontoftthethospitaltremainedtincomplete.

 NangaltGeneraltHospital

ThisthospitalthadtatsimilartstoryttotthattoftPatiala.tThetconstructionthadttobetstoppedtduettotthe

tshortagetoftgovernmenttfunds.tIttwastthentdecidedttotconverttittintoprojecttbuttlatertittwas

42
tfelttthattthetpatientstintthattareatweretoftdiversetbackgroundtsotittwastdifficultttotprovidet

servicestattatuniformtprice.t(Singh,t2011)

 MohalitandtPatialatHospitals

ThetsettingtuptofttwotsupertspecialitythospitalstattMohalitandtPatialatinagreementtwithtMaxt

healthcarethastprovedttotatveryteffectivetstep.tAthealthtfundtisgeneratedtfromtthe

tgovernmenttsharetoftrevenuetfromtthethospitaltwhichtistusedttotprovidetsubsidisedthealtht

servicesttotthetpoor.ExcepttthetMaxthealthcaretproject,tthetothertPPPtinitiativestintthetstatet

havetfacedtseveraltchallenges.tFirstlytduettotthetlocaltvariationstwithintthetstate,tsimilarttype

toftprojectstcannottbetlaunchedteverywhere.tSecondly,tthesetprojectsthavetattemptedtto

texpandtthetinfrastructuretrathertthantplanningttotmaketoptimumtusetoftthetexistingtprivatet

sectortinfrastructure.tThetreasontbehindtmoretinvestmenttontinfrastructuretseemsttotbetthe

tgovernment’stdesirettotshowtthattittistdoingtatlotttotimprovetthetpublicthealth.

Decentralisation

Int1993,tthetWorldtBanktintitstreporttrecommendedtthetdecentralisationtoftmanagementt

ofthealthtservicesttotincreasetefficiencyt(ThetWorldtDevelopmenttReport,t1993).tAsta

tresulttvarioustdevelopedtandtdevelopingtcountriestimplementedtthistideatandt

experiencedtmixedtresults.tIntcountriestliketColombiatandtPapuatNewtGuinea,tthis

tprocesstturnedtoutttotbetsuccessful,thowevertintothertcountriestliketBangladesh,tNigeria

,tKenyatittfailedttothavetanytpositivetimpactt(Sekher,t2005).tIntIndia,tthetruraltself

tgovernancetsystem,tPanchayatitRajtInstitutionst(PRIs)twastformedtthrought73rd

tconstitutionaltamendmenttacttint1992.tHealthtwastonetoftthet29tfunctionsttransferredttot

43
thetPRIs.tAlthoughtsometoftthetstatesttransferredtthetpowerstandtfundsttotthetPRIstbut

toveralltthetresponsetwastnottverytencouraging.

Punjabthastalsotbeentverytslowtintdevolvingtpowerttotthetpanchayattbodies.tHowever,

tthetlaunchtoftNRHMtgavetantimpetusttotthetdecentralisation.tThistreformtreflectstintthe

tDistricttHealthtMissiontwhichtwastlaunchedtastatparttoftNRHMtint2005.tThetdistrictthe

althtmissiontwasttotbetcarriedton,tundertthetleadershiptoftZilaParishadtwithtdistrict

thealththeadtastconvenerttherebytindicatingtthettransfertoftpowerstbytthetDepartmenttoft

HealthtandtFamilytWelfare.tAnothertstepttakenttotincreasetthetcommunitytparticipation

tistthetformationtoftRogiKalyaniSamitist(RKS)tattdistrict,tsubtdivisional,tCHCtandtPHCt

levelst(Kaurtettal.t2012).tInt2006,tthetPunjabtgovernmenttintroducedtthetconcepttoft

decentralisationtintthethealthtsectortintorderttotbettertunderstandtandtfulfiltthetlocalt

healthtneedstoftthetruraltareas.tAntinitiativetwasttakenttottransfert1186tSubsidiary

tHealthtcentrest(ruraltdispensaries)touttofttotalt2951ttotPanchayatitRajtInstitutions.

tUnderthistscheme,tthetzilaparishadstappointtatservicetprovidertforteverytdispensarytwho

tis,tintturn,tresponsibletforthiringtthetrequiredtworkforcetintthetSHC.

ThetcriticstaretoftthetviewtthatthandingtovertoftruraltdispensariesttotPRIsthastresultedtint

twotparallelthealthtsystemstintPunjab.tAttthettimetoftinitiatingtthistreform,tthetPunjabtgo

vernmenttpromisedttotsupplytmedicinesttoteachtdispensaryttotbetprovidedttotpoor

tpatientstfreetoftcost.tHowever,tthetactualtpicturetistquitetgloomytastthetdispensaries

tlacktadequatetfacilitiestandtthetmedicinetsupplythastbeenttotallytstopped.tThe

tunavailabilitytoftbasictmedicinesthastleadttotathugetdeclinetintthetnumbertoftpatientst

visitingtthetdispensaries.tInt2006,tthesetdispensariestweretvisitedtbytnearlyt80tlakht

patientstpertyeartwhichtcametdownttot15tlakhst(ThetTimestoftIndia,t2014).tThetofficials

toftthetRuraltDevelopmenttandtPanchayatstDepartment,tresponsibletfortsupervisingtthe

44
tdispensariesthavetfoundttotbetleasttconcernedtabouttthetsupplytoftthetmedicines.tDuetto

tlacktoftexposurettottrainingtandtmedicaltseminars,tthetruraltmedicaltofficersthave

tstartedtdemandingttheirtmergertwithtthethealthtdepartment.tMoreover,tthetdoctorstare

tfacingtlottoftproblemstintgettingttheirtsalaries.

ThetrepeatedtproteststoftPunjabtRuraltMedicaltOfficerstAssociationtagainsttthetpoor

tconditiontoftthetruralthealthtcaretsystemtintthetstatetclearlytsignifytthetfailuretoft

decentralizationtintPunjabthealthtsector.tThetpresenttpicturetoftruralthealthtsystemt

exposestthetshallowtclaimstoftthetPunjabtGovernmenttthattittistprovidingtoptimalthealtht

servicestintthetstate.tItthastbeentobservedtthattthetgovernmentthastimplementedtonlyt

administrativetdecentralizationtwhichtistnottatsolutionttotthetfaultythealthtcaretsystem.t

Theretistatneedttottransfertdecisiontmakingtpowertattthetlowertlevelstsotthattthetresource

stcantbetusedtaccordingttotthetlocaltneeds.

CurrenttHealthtScenariotoftPunjabtintthetbackdroptoftLiberalisation

MajortHealthtIndicators

Astthethealthtstatustistatmultidimensionaltconcept,tsotitstexacttmeasurementtisthard.

tHowever,tatnumbertoftindicatorstaretoftentusedttotmeasuretthetstatustofthealth.tTheset

includetthetBirthtRate,tDeathtRate,tInfanttMortalitytRatet(IMR).tIntthistsectiontthe

variousthealthtindicatorstintPunjabthavetbeentanalyzedtfortthetlasttfewtdecades.

45
t

46
 IntspitetoftthetfacttthattPunjabtistheadingtfastttowardstthetachievementtoft

MillenniumtDevelopmenttGoalstoftthesethealthtindicators,ttheretaretvariousthealth

tissuestwhichtneedtattention.tOnetoftthesetissuestistruralturbantdifferencestintthethealth

tindicators,twhichtistclearlythighlightedtintthetforegoingtanalysis.tInt2013,tthetbirthtrate

tintruraltPunjabtwast16.3tcomparedttot14.7tinturbantPunjab.tSimilarly,tthetruraltdeath

tratet(7.5)twasthighertthanttheturbantdeathtratet(5.4).tAstregardstthetInfanttMortality

tRate,tittwast28tintruraltPunjabtandt23tinturbantPunjab.tThetlacktoftphysicalthealth

tfacilities,tmanpowertandtbasictmedicinestintthetruraltareastistthetprimarytreasontfor

tthesetdisparitiest(Gilltettal.,t2010).tIntthetabsencetoftsoundthealthtfacilities,truraltpeople

tdependtontthetexpensivetandtpoorthealthtservicestprovidedtbytthetunqualifiedtdoctors.

tIntorderttotbridgetthistgap,tthetPunjabtgovernmenttneedsttotputtthetruralthealthtissuest

ontitstagenda.

47
 Tablet5.2

ComparisontoftHealthtIndicatorstoftPunjabtwithtothertstates

S t a t e PertcapitatNSDP I M R B i r t h t R a t eD e a t h t R a t e

P u n j a b9 4 . 2 3 02 71 8 . 25 . 7

K e r a l a1 , 0 5 , 2 2 0 1 51 6 . 75 . 9

Maharashtra1 , 2 0 , 0 7 5 2 61 7 . 55 . 2

T a m i l t N a d u1 , 1 4 , 8 6 1 2 41 6 . 66 . 3

M a n i p u r4 6 , 5 4 31 31 5 . 53 . 0

T r i p u r a7 2 , 6 0 92 91 4 . 7t 4 . 3

Source:tRuraltHealthtStatisticst2018,tNationaltHealthtProfiletoftIndiat2018

Economictdevelopmenttandtsocialtdevelopmenttaretcomplementaryttoteacht

ther.tThetlacktoftattentionttotthetsocialtsectortresultstintatslowertpacetofteconomic

tdevelopment.tAlthoughtthethealthtindicatorstintPunjabtaretbettertthantthetnationalt

averagetandtmanytstatestoftIndia,tbuttgiventitsteconomictdevelopment,tthethealthtout

comestaretnottsatisfactory.tAstpertthetIndiantHumantDevelopmenttReportt(2011),t

Punjabtrankst5thtintHumantDevelopmenttIndex.tHowever,tthetstatethastshowntatvery

tlowtimprovementtintthethealthtindextastittwast0.632tint2000tandt0.667tint2008.tInt

spitetofthavingthighertNSDPtpertcapitatthantthetstatestliketManipurtandtTripura,t

Punjabtrankstbehindtthemtontthethealthtindicators.tThetIMRtintManipurtist13tas

48
 tcomparedttot27tintPunjab.tMaternalthealthtcontinuesttotbetantissuetintPunjab

.tSimilarly,tthetBirthtratetintPunjabt(18.2)tisthighertthantKeralat(16.7),tManipur

t(15.5),tTripurat(14.7).

SincetIndiatrankstlowtontthetbasistoftWorldtHumantDevelopmenttIndextwitht

antinefficientthealthtsystem,tittcannottbetconsideredtastatgoodtbenchmark.tIntordertto

thavetatbroadertviewtoftthetPunjabthealthtstatus,titstcomparisonttotinternational

tstandardstistalsotimportant.tThetIMRtandtlifetexpectancytoftPunjabtareteventlower

tthantthetcountriestfallingtintthetcategorytoftMediumtHumantDevelopmenttIndex.

tParaguay,tMaldivestandtVietnamthavetIMRtoft19,t9tandt18tastcomparedttot26tin

Punjabt(WHOtstatistics,t2014).tSimilarly,tthetlifetexpectancytoftmaletandtfemaletint

Vietnamtist71tyearstandt80tyearstwhichtaretquitethighertthantPunjab.tThis

tcomparisontbringsttotlighttthetpositiontoftPunjab'sthealthtsystemtintthetworld.tInt

thistsituation,tittbecomestimperativetfortthetPunjabtgovernmentttotbringtsubstantial

treformsttotimprovethealthtsectortinttermstoftmanpower,tphysicaltfacilitiestandt

expenditure.

HealthtExpenditure

Onetoftthetreasonstfortthetdifferencetintthetpacetofteconomictdevelopmenttan

dtsocialtdevelopmenttintPunjabtistthetlowertallocationtoftresourcesttotthetsocialt

sectortparticularlytthethealthtsector.tIntabsolutetterms,tthetgovernmentthealtht

expendituretontrevenuetaccountthastincreasedtfromtRst196.97tcrorestint1990-

91ttotRst3120.79tcrorestint2017-

18.tHowevertintrelativetterms,tthethealthtexpenditurethastdeclinedtgradually.tFiguret

5.4tshowstthattint1990t-

91tthetsharetofthealthtexpendituretintgovernmenttexpendituretwast7.75tpertcentt

49
whichtdecreasedttot3.43tpertcenttint1995-

96tandtittwastthetlowestt(3.15tpertcent)tint2007-

08.tAccordingttotthetrecenttStatisticaltAbstracttoftPunjab,t5.65tpertcenttoftthet

governmenttexpenditurethastbeentspenttonthealthtandtfamilytwelfaretint2017t-

18twhichtiststilltlowertthantthetpre-

reformstperiod.tFiguret5.4tshowsttwotsharptdeclinestintthethealthtexpendituretintthet

yeart1990-91tandt1995-

96twhichtmarktthetintroductiontofteconomictreformstandtthetformationtoftPunjabtHe

althtSystemtCorporationtrespectively.tAlthoughtthetPHSCttriedttotincreasetthetpublic

texpendituretonthealthtaftertitstformationtbuttittcouldtnottretaintittfortlong.tAtsimilart

trendtistobservedtwhenthealthtexpendituretistseentastatproportiontoftdevelopmentt

expendituretandtsocialtsectortexpenditure.tInt2017-

18tthetgovernmenttexpendituretonthealthtwastRs.t3120.79twhichtistnearlytone-

thirdtoftthetexpendituretontEducation,tsportstandtart.tDespitetthetfacttthatthealthtistan

timportanttdeterminanttofthumantcapital,tthetPunjabtGovernmentthastallocatedtlesser

tfundsttothealthtastcomparedttotothertsectors.

50
 Tablet5.3

PublictHealthtExpendituretontrevenuetaccount

Y e a rGovernmenttExpenditureton % t o f t H e a l t h t E x p e n d i t u r e t t o

HealthtandtFamilytwelfaret(Budget G o v e r n m e n t t

EstimatestintcroretRs.)

1 9 9 0 1 9 6 . 9 7 7 . 7 5

2 0 0 0 7 6 1 . 6 2 5 . 8 3

2 0 1 0 1 2 8 1 . 4 0 3 . 8 4

2 0 1 3 2 3 6 8 . 9 7 5 . 3 3

2 0 1 5 2 5 6 1 . 2 9 5 . 2 1

t 2 0 1 6 t t 2 8 3 4 . 2 5 t 5 . 1 8

t 2 0 1 8 t 3 1 2 0 . 7 9 t 5 . 6 5

Source:tStatisticaltAbstracttoftPunjab,tVarioustissues

51
52
Besidestthethealthtexpendituretbytthetstatetgovernment,tthethealthtsectortoftPunjabtalsot

dependstontthetfundstallocatedtbytCentraltgovernmenttundertvariousthealthtprogrammes.

tThetfundstfortthesetschemestaretreleasedtundertthetNRHM.tTablet5.5tshowstthetpercent

agetoftcommittedtfundstreleasedtundertNRHMtandtthetproportiontoftthetreleasedtamount

twhichtwastunspenttintthetstate.

Thetanalysistoftdatatrevealstthattduringtthetperiodtbetweent2005-

06tandt2012-

13,t47.6tpertcenttoftthettotaltfundstreleasedtweretunspenttintPunjab.tIntcomparison

,tthistpercentagetistverytlowtintmosttoftthetothertstates.tIttshowstthetfailuretoftthe

tPunjabtgovernmentttotutilizetthetfundstreceivedtundertNRHM.tThetgovernment'stin

abilityttotdotsotcantbetattributedttotlacktoftplanstandttheirtexecutiontintthetstate.tIn

torderttotimprovetthethealthtstatustoftPunjab,tittistessentialttotincreasetthetabsorptivet

capacitytoftthetstatetandtthetallocationtoftresourcestbytthetstatettotthethealthtsector.

tIttalsotmaytbetduettotthetfacttthattsometschemetoftthetcentraltgovernmentthastcondit

iontoftmatchingtsharetoftthetstate.

tHealthtcaretUtilisationtandtCosttofttreatmenttintPunjab

Thetlowtleveltoftpublicthealthtspendingthastforcedtthetpeoplettotrelytontthe

tprivatethealthtservices.tThetdatatrevealstthattintPunjabtouttoftthettotalthealth

texpenditure,t81.8tpertcenttistprivatetexpendituretandtonlyt18.2tpertcenttistpublict

expendituret(HumantDevelopmenttReporttIndia,t2011).tThetovertdependencetof

tPunjabthealthtsystemtontthetprivatetsectortcantbetseentcomparingtittwithtstatestliket

HimachaltPradeshtwheretthetpublictexpendituretonthealthtistnearlyt42tpertcent.t

Eventattthetnationaltlevel,tthetpublicthealthtspendingtformst30tpertcenttoftthettotal

thealthtspending.tFurther,touttoftthetprivatetexpendituretnearlyt76tpertcenttistouttoft

53
pockettexpendituretintPunjab.tThetratiotoftgovernmenttandtprivatetexpendituret

furthertindicatestlowtleveltgovernmenttspendingtonthealthtservicestintPunjab.

ThetexpansiontoftprivatethealthtsectortintIndiathastnottonlytaffectedtthe

tavailabilitytoftthethealthtservicestbuttalsotthetcosttofthealthcaret(Uplekar,t1989).t

AccordingttotatreporttbytNationaltSampletSurveytOrganizationt(NSSO,t60thtround),t

thetaveragetmedicaltexpendituretperthospitalisationtcasetintatprivatethospitaltistalmos

ttmoretthantdoubletthantthattintatpublicthospital.tInt2004,tthetaveragetmedicalt

expendituretperthospitalisationtcasetintatprivatethospitalt(urbantarea)twastRs.t19035t

astcomparedttotRs.t10,323tintPublicthospital.tThetrecenttreporttoftNSSO’st71st

troundtrevealstthattintruraltPunjab,tthetaveragetexpendituretperthospitalisationtcasetis

tRs.t27,718twhichtistalmostttwicetthantthattoftruraltIndia.tEventinttheturbanthospitali

sationtcases,tthetexpendituretintPunjabtisthighertthantthattofturbantIndia.tOnetoftthet

majortreasonstfortthistexorbitanttincreasetintthetcosttoftprivatethealthtservicestistthe

trisingtcosttoftmedicalteducationtintPunjab.tCurrently,t10tmedicaltcollegestare

trunningtintPunjabtundertBabatFaridtUniversitytoftHealthtSciences.tThetfeestfor

tMBBStandtBDStintthesetcollegestarethighertthantthosetoftothertstates.tInt2014,the

ttuitiontfeestoftMBBStfirsttyeartintGovernmenttcollegestoftPunjabthikedttotRst2.2

tlakhstmakingtittfifteenttimestthetfeestintGovernmenttMedicaltCollege,tChandigarh.t

EventthetstatestliketHimachaltPradeshtandtJammut&tKashmirthavetthetMBBStfeest

astlowtastRst30,000tandtRs.t13000tpertyeartrespectivelyt(HindustantTimes,t30tJunet

2014).tDoctorswhotarettrainedtbytmakingtsuchthugetinvestmentsttransferttheir

tburdenttotthetpatientstbytincreasingtthetchargestfortthethealthtservicestwhentjointthe

irtprofessionttotrecovertthetinvestmenttmadetonttheirteducation.tOvertthetyearst(1995

-96ttot2004),ttherethastbeentattremendoustincreasetintthetcosttofttreatmenttintboth

tgovernmenttandtprivatethospitals.tThetcosttofttreatmenttinturbantprivatethospitalstin
54
tPunjabtincreasedt3.1ttimestwhereastthetincreasetintgovernmentthospitalstwast1.9

ttimes.tAlthoughttherethastbeentantincreasetintaveragetmedicaltexpendituretpert

hospitalizationtattthetnationaltlevel,tbuttintPunjabtverytsharptescalationtwastobserved

.tSimilarly,tthetaveragetexpendituretontchildbirthtintatruraltgovernmentthospitaltin

tPunjabtistnearlytthreettimestthattoftnationaltaverage.

Tablet5.4

SharetoftPublictandtPrivatethealthtcaretproviderstinthospitalizedttreatment

Rural Urban

PrivatetHospitalt

G o v e r n m e n t PrivatetHospitalt(%) GovernmenttHospitalt(%) ( t % )

Hospitalt(%)

R o u n d s Rounds t R o u nd s Rounds

5 2 n d7 1 s t 52nd 7 1 s t 5 2 n d7 1 s t 52nd 7 1 s t

Punjab 3 9 . 4 2 9 . 3 60.67 0 . 7 2 7 . 630.2 72.36 9 . 8

I n d i a4 5 . 34 1 . 9 54.75 8 . 1 4 3 . 13 2 56.96 8

Source:tNSSOt52ndtreportt1995-96t,t71sttroundtreport,t2015

55
 Thoughtthetprivatethealthtsectortistconcentratedtinttheturbantareastandtistunaf

fordablettotthetmajoritytoftthetpeople,tstilltatlargetproportiontoftpopulationtrelieston

tthistsectortfortmajortandtminortailmentst(ThetHindu,t2005).tFiguret5.5tshowsthowt

thettrendtinthospitalisedttreatmenttcasesthastchangedtovertyears.tThetimpacttoft

economictrestructuringtcantbetclearlytseen,tastthethighertpercentagetoftpatients

(bothtinturbantandtruraltarea)toptedtfortgovernmentthospitalstbeforetliberalisation

thadtshiftedttotprivatethospitalstaftert1991teconomictpolicy.tThetgovernmentthospital

stservicestaretusedtmoretintruraltareast(41.7tpertcent)tthantinturbantareast(38.2tpert

cent).tIttistpertinentttotmentiontthattthetstructuraltadjustmentstprogrammetintroduced

tbytthetcentraltgovernmenttint1991-

92tpromotedtthetgrowthtoftprivatethealthtsector.tUndertthetimpacttoftthetprivate

thealthtsector,tthetusertchargestweretimposedtbytthetgovernmenttfortpublicthealth

tservicestwhichtactedtastanothertbarrierttothealthtcaretaccess.tAlltthesetfactorsthave

tresultedtintthetshifttoftpatientstfromtgovernmentttotprivatethealthtservices.

Tablet5.4tshowstthattthetincreasingtcosttofttreatmenttintgovernmentthospitalst

andtlacktoftadequatethealthtservicestledttotatshifttoftpatientstfromtthetpublictsectortto

tthetprivatetsector.tWithtthreettimestrisetintthetmedicaltexpendituretintruraltgovernm

entthospitals,tthetpeopletseekingttreatmenttintthesethospitalstdecreasedtfromt39.4tper

tcentttot29.4tpertcent.tAccordingttotthet71sttroundtreporttoftNSSOt(2015),tthetsharet

oftgovernmenthealthcaretproviderstiststilltverytlowtastcomparedttotthetprivatetsector.

tThetincreasedtusetoftprivatethealthcaretservicesthastresultedttotthethighertfinancial

tburdentontthetpoor.tItthastbeentnoticedtthattthethealthcaretistonetoftthetprimarytpurp

osestfortwhichtthetsmalltandtmarginaltfarmerstintPunjabtacquiretcreditt(Singh,t2010)

.tKeepingtthistproblemtintview,tthetstatetgovernmenttlaunchedtBhagatPurantSingh

tSehatBimaYojanatint2013ttotprovidetfreethealthtservicestupttotRs.30,t000ttotBPL
56
population.tThetschemetaimedttotcovert1.54tfamiliestbuttittwastdiscontinuedtint2015

tduettotnontrenewaltoftthetcontracttwithtthetprivatetinsurancetcompaniestinvolvedttot

providetthistservice.tLatertthetgovernmenttannouncedtthattthetschemetwouldtbetrun

tintcollaborationtwithtthetalreadytfunctioningtcentret-

statetjointthealthtinsurancetschemetnamedt'RashtriyaSwasthyaBimaYojanat(RSBY).t

ThetRSBYtwastlaunchedtint2008tandtaftertseventyearstoftoperationsti.e.ttillt2015tthe

tschemetcouldtcovertonlyt232352tfamiliestastagainsttthettargettoft454255tintthe

twholetstate.tBesidestthis,tPunjabtNirogiYojanatwastalsotlaunchedtint2007t-

08ttotprovidetmonetarytsupportttotthetpoortpatientstupttotthetextenttoft1.5tlakhs.t

However,tthetimplementationtoftthesetschemestcouldtnottprovidetmuchtreliefttotthet

majoritytoftpublictintPunjabtwhotaretbeingtcompelledttotavailtcostlytprivatethealth

tservice.

Thetshortagetoftthetdoctorstandtothertmedicaltstafftinthealthtcentrestistnottont

accounttofttheirtunavailability,trathertittistduettotlacktoftadequatetsalariestand

tincentivestofferedtbytthetgovernmentttotthetnewtdoctors.tThetdoctorstpreferttotwork

tinttheturbantareastwheretthetprivatethospitalstpaytequalttotortmoretthantthet

governmenttsector.tThetnontpractisingtallowancetshouldtbetverythightsotthattthey

tfocustontgovernmenttjobtandtfeeltlesstinterestedtintprivatetpractice.tThetgovernment

thastalsotbeentforcedttotkeeptthesetpoststvacanttundertthetpressuretoftthetbigtprivatet

andtglobaltplayerst(Singh,t2010).tDespitetthetavailabilitytoftatlargetnumbertof

tqualifiedtdoctorstintthetstate,tmoretthanthalftoftthetsanctionedtpoststoftdoctorstatt

CHCstaretlyingtvacant.tMoreover,tthetCHCstaretmanagedtbytIAStofficerst(PHSC)t

buttnottbytspecialisttdoctors,ttherefore,tthetneedstoftthetdoctorstaretnottproperly

tunderstood.tBesidestthis,tabsenteeismtoftdoctorstduringtthetworkthours,tespecially

tintthetruraltareastistthetmajortproblemtfacedtbytthetvisitingtpatients.tIntPunjab,

57
tnearlyt50tpertcenttoftthetMedicaltOfficerstintchargetandt39tpertcenttoftthetdoctorst

weretfoundtabsenttfromttheirtposts.tSimilarly,tthetabsencetratetoftthetnursestwasthigh

tast45.9tpertcentt(Chaudarytettal.,t2008).tAmongtdoctors,t11tpertcenttoftthet

absenteeismtcasestweretunexplainedtasttheytweretabsenttfortnotreason.tIntspitetof

tbeingtathightincometstate,tPunjabthastnotttakentanytstepstregardingtabsenteeismtand

titstabsencetratetistsimilarttotthetlowtincometstatestliketBihar.

Thettotaltnumbertoftregisteredtdoctors,tnursestandtmidwivestworkingtin

tPunjabthastcontinuouslytincreasedtsincetlasttthreetdecades.tInt2013,tthetnumbertof

tdoctorstwastthreettimestthantthattint1980.tTherethastbeenttenttimestincreasetintth

tetnumbertoftgovernmenttnursest4557tint1980ttot50629tint2013.tIntspitetoftthe

growingtnumbertofthealthtworkforce,tthetpopulationtservedtperthealthtworkertistvery

thightintsometoftthetdistrictstduettotdisparitiestinttheirtdistributiontandtthe

tpopulationtdifferencest(Purohit,t2009).

PerformancetoftNationaltHealthtProgrammestintPunjab

Althoughthealthtistatstatetsubject,tthetcentretkeepsttakingtvariouststepstto

helptthetstatestintimprovingtthethealthtstatustoftthetpeopletbytmakingthealthtservicest

moretaccessible.tOnetoftsuchtattemptstmadetbytthetcentraltgovernmenttwastto

tprovidetadditionaltresourcesttotthetstatestbytlaunchingtoftNationaltRuraltHealth

tMission.tBesidestintroducingtnewthealthtprogrammes,tmanytexistingtonestwere

tbroughttundertthetpurviewtoftNRHM.tThetprogrammestundertNRHMtaretfinancedt

bytthetcentretandtthetstatestintthetratiot85:15tbuttthetresponsibilitytoftimplementation

tliestwithtthetstatetgovernments.tIntthistsection,tthetperformancetoftPunjabtintthe

timplementationtoftvarioustdiseasetcontroltprogrammesthastbeentdiscussed.

58
RevisedtNationaltTBtControltProgrammest(RNTCP)

RNTCPtwaststartedtintPunjabtint2001.tInt14tyearstoftitstoperation,t134tTB

tunitstandt12216tDirectlytObservedtTherapyt(DOT)tcentresthavetbeentsettuptintthet

state.tThetsuccesstratetintthetstatetistsatisfactorytatt86tpertcenttbuttthetgreatertcauset

oftconcerntistthetincreasingtnumbertoftMultidrugtResistanttTBtpatientstwhichtare

difficulttandtexpensivettottreat.tThetnumbertwast340tint2013tandtittdoubledtint2014t

(TimestoftIndia,t2013).tDespitetgettingtadequatetfundstundertRNTCP,tthetstate

tgovernmentthastfailedttotspendtthetreleasedtfundstfullyttottackletthistproblemt(TB

treportt2014).tOnetoftthetrecenttdevelopmentstundert'TB-

freetIndia'tprogrammetistthetstartingtoft“missedtcalltcampaign”.tThetgovernmentthas

tissuedtattolltfreetnumber,twheretTBtpatientstcantgettthetrequiredtmedicalt

informationtbytcallingtortgivingtatmissedtcall.tThethealthtdepartmenttoftPunjabtneed

sttotmaketmoretrigorousteffortstintorderttotachievetthetdreamtoftTB-freetstate.

NationaltAIDStControltProgrammet(NACP)

NACPtwastlaunchedtintPunjabtbytformingtPunjabtstatetAIDStcontroltsociety.

AlthoughtthetprevalencetratetoftHIVtintPunjabtist0.15tpertcenttwhichtistlowertastcompar

edttotIndiatbuttthettotaltnumbertoftcasesthastgonetuptfromt25,082tintMarcht2011ttot45,

948tintAprilt2014t(Dailymail,t2014).tInt2014-

15,tAmritsartdistrictthadtthethighesttnumbertoftHIVtpositivetcasestintthetstate.tOnetof

tthetmajortreasonstfortthetsuddentrisetintHIVtcasestistthetincreasingtmenacetoftdrugs

.tAccordingttotatreporttbytNationaltAIDStControltOrganisationt(NACO),tPunjabthastthet

highesttnumbertoftInjectedtDrugtUserst(IDU)tintIndia.tIntthetabsencetoftatpolicytto

tcontroltthetrisingttrendtoftIDUtintPunjab,tittistverytdifficultttotcontroltHIV.tThetpeoplet

shouldtbetmadetawaretthattinjectingtdrugstincreasestthetrisktoftAIDS.

59
PunjabtDegradestIntHealthtSector,tFacestAtBurdentOftObesitytAndtPoortNutrition

ThetpopulartcaricaturetoftPunjabististoftatrobust,trelatively-

richtpeopletmadetthattwaytbytheartyteatingtandtenergetictliving.tThetrealityttoday:t

Wastingt(lowtweight-for-

height)tamongtchildrenthastincreasedtfromt9.2tpertcenttint2005ttot17.3tpertcenttint2018,t

andtonetintfourtiststilltstuntedt(lowtheighttfortage).

AstPunjab,tattonettimetamongtIndia’stfastest-

growingtandtrichesttstates,tpreparestfortassemblytelections,tittistnowtoftenttermedtastat

“once-rich”tagrariantstate,titsteconomytdecliningtandtill-

healthtplaguingtpeopletoftalltages.

StrongtGrowthtintHealthcaretExpenditure;

HealththastbecometonetoftthetmajortsectorstintIndia,tbothtinttermstoftoftincometandt

employment.tThetindustrytistgrowingtatttremendoustpacetduettotitststrengtheningtint

coverage,tservicestandtIncreasedtspendingtbytpublictandtprivatetactors.t

 Duringt20010-

22,tthetmarkettshouldtregistertatCAGRtoft16.28percenttIttistestimatedtthattthe

ttotaltsizetoftthetsectortwilltreacht$t160tbilliontfort2015tandtUSt$t372tbilliontint

2022.t

 ThethospitaltindustrytintIndiatstandstatt4tbilliontRst(USt$t61.79tbillion)tin

tFY17tandtcompoundtannualtgrowthtistexpectedttotincreasetRatet(CAGR)toft

15-16tpercentttotreachtRst8.6tbilliont(USt$t132.84)tbillions)tbytFY22.

60
 300

250

200

2010
150
2015
2020 FE
100

50

0
2010 2015 2020 FE

Tablet5.5tBirthtRate:

Y E A R R u r a l U r b a n Combined

2 0 0 0 2 2 . 7 1 8 . 6 2 1 . 6

2 0 1 0 1 7 . 2 1 5 . 6 1 6 . 6

2 0 1 5 1 5 . 9 1 4 . 2 1 5 . 2

2 0 1 8 1 5 . 2 1 3 . 8 1 4 . 5

tTablet5.6tDeathtRate:

Y E A R R u r a l U r b a n Combined

2 0 0 0 7 . 9 5 . 9 7 . 4

2 0 1 0 7 . 7 5 . 8 7 . 0

2 0 1 5 6 . 9 5 . 1 6 . 2

2 0 1 8 6 . 5 4 . 8 5 . 7

61
Tablet5.7tInfanttMortalitytRate:

Y E A R R u r a l U r b a n Combined

2 0 0 0 5 6 3 8 5 2

2 0 1 0 3 7 2 8 3 4

2 0 1 5 2 4 2 0 2 1

2 0 1 8 2 1 1 4 1 8

62
CHAPTERt–t6

FINDINGSt&t

CONCLUSION

63
 FINDINGSt

HEALTHtSECTORtINtPUNJAB:tAtPROFILE

ThetStatetoftPunjabtwastformedtintthetyeart1966taftertthetthentStatetoftPunjabtwas

tdividedtintottwotmoretStates,tHaryanatandtHimachaltPradeshtontlinguistictcapacity.tThet

wordtPunjabtistderivedtfromttwotPersiantwordst'Punj'tandt'Aab'twhichtmeanstlandtoftfive

trivers—Indus,tRavi,tBeas,tSutlejtandtJhelum.tIttistsituatedtintthetNorth-

westerntregiontoftIndiatandtsharestborderstintthetNorthtbytJammutandtKashmir,tintthetWe

sttbytPakistan,tintthetNorth-

EasttbytHimachaltPradeshtandtintthetSouthtbytHaryanatandtRajasthan.tItthastattotaltarea

toft50,362tsq.tkm.tandtoccupiest1.5tpercenttoftthettotaltareatoftthetcountry.tAccordingttot

Censust2011,tPunjabthastatpopulationtoft2,t77,t04236tcrtandtrankstfifteenthtwhereastU.P.t

rankstfirsttamongtalltIndiantStates.tPunjab'stchildtsextratiotcontinuesttotfall,tindicatingtthat

tfemaletfeoticidetandtinfanticidetremaintrampant.tProvisionaltdatatreleasedtbytthetcensust

officetfort2011tshowstthattPunjabt(846tgirls/1000tmales)tandtHaryanat(830tgirls/1000tmal

es)tremaintattthetbottomtoftthettable.tKeralattopstthetlisttwitht1084tfemalestpert1000tmale

s.

PUNJAB:tAtSOCIO-ECONOMICtPROFILE

PunjabtistmainlytantagrariantStatetandtmoretthant60tpercenttoftthetpopulationtlivestintruralt

area.tThetStatetistantexclusivetlandtoftmonumentstofthistorictimportance,tmesmerizing

tscenestoftnaturaltbeauty,tfertiletgreenery,tinspiringtreligioustsitestandthastenjoyedtatprime

tpositiontintsports.tThetStatethastwontvarioustawardstnationallytandtinternationallytin

t'kabbadi',tathletics,tweight-lifting,t'kho-kho'tandthockey.

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PunjabtistonetoftthetfastesttdevelopingtStatestintIndia.tDuringtthetlasttdecade,tPunjabthast

maintainedtatsteadytgrowthtandtthetaveragetrealtGSDPtoftthetStatethastgrowntattaroundt8

tpercentt(FinancialtYeart2005ttotFinancialtYeart2018).tItthastincreasedtmoretthantdouble

tfromtaroundtRs.t92146tcroretintFY2005ttotaroundtRs.t204620tcroretintFY2018.tDuringtthe

tFY2018ttertiarytsectortcontributedtatsignificanttsharetoftaroundt42tpercenttintthetGSDPt

followedtbytprimarytsectortatt28tpercent,tthetsecondarytatt29tpercenttrespectively.tHowever,

tthetsharetoftagriculturethastdeclinedtfromtaroundt32tpercenttintFY2005ttot21tpercenttint

FY2018.

ThetStatethastbeentrankedtfirsttintagriculture,tinfrastructure,tandtconsumertmarkets,tPunjabt

standstsecondtontthetbasistoftvarioustsocio-

economictparameterstviz.tinvestmenttenvironment,tinfrastructure,tfoodtgraintproduction

tagriculture,tprimaryteducationtandtconsumertmarkets.tAmongtthet15tbiggertStatestoftIndia,t

Punjabtstandst2ndtintoveralltcompetitivenesstrankingtoftthetStates.

PunjabtistrankedtattthetfifthtinttermstoftpertcapitatincometamongtalltthetIndiantStates.tGross

tfiscaltdeficittoftthetStatetastatpercentagetoftGSDPthastincreasedttot5.2tpercenttduringt

FY2018tastcomparedttotthet4.9tpercenttintFY2017.tDuringtrecenttyears,tthetFDItinflowstin

tthetStatethavetpostedtantimpressivetgrowth.tHowever,tthetregiontconstitutestaround t1

tpercenttoftthettotaltFDItinflowstintIndia.t

Punjabtistonetoftthetlargesttproducerstofttwotcropsti.e.twheattandtricetintIndia.tMajortcropst

growntincludetwheat,tpaddytandtsugarcane.tThetmaintfruitstgrowntintStatetaretorange,t

'kinnow',tmango,tguavatandtgrapes.tThetStatetistmakingtspecialteffortsttotincrease

tcultivationtoftpulses,tcotton,tmaizetandtoilseeds.tThetbankingtsectortintthetStatetis

tdominatedtbytnationalizedtbankstwithtmoretthant2000tbranchestoftwhichtSBItandtits

tassociatesthavingt822tbranches,tfollowedtbytprivatetsectortbankstwitht428tbranches,

65
tregionaltruraltbankstwitht251tbranchestandtforeigntbankstwitht8tbranches.tPunjabthast

emergedtastatkeythubtforttextiletbasedtindustriestincludingtreadymadetgarmentstyarntand

thosiery.t

ThetStatethastatrichtculturetandtheritagetcoupledtwithtgoodttourismtinfrastructure,twhich

tmakestittonetoftthetfavorabletdestinationstbytdomestictandtinternationalttourists.tThetState

tistalsotstrivingttotpromoteteco-tourismtintthetState.

highertthantthattofthillytStatetoftJammutandtKashmirtwitht5.4tpercenttpopulationtliving

tbelowtthetpovertytline.

ECONOMICtREFORMStANDtECONOMYtOFtPUNJAB

AstmentionedtintthetthirdtstatustreporttoftPunjabtGovernancetReformCommission,tthet

reasontbehindtslowteconomictgrowthtintthetStatetduringtthetpostreformtperiodthastbeen

tduettotslowtgrowthtintthetagriculturetsector.tThetslowdowntintthetgrowthtoftagriculture

tsectorthastcontributedtsignificantlyttotthetlessertgrowthtoftpertcapitatincometoftthe

teconomytoftPunjab.tFurthermore,tthetdatatintthetreporttshowstthattindustrialization

tprocesstintthetStatethastgonetdowntquitetconsiderably.tAlso,tthetcentralizedtmonetarytand

tfiscaltpoliciesthavetinitiatedtthetprocesstoftthrowingtouttinvestmenttfromtthetState,twhich

thastadverselytaffectedttheteconomictgrowthtoftthetPunjabtState.tfromtmosttleadingtand

tdynamicteconomyttotatstragglertonetwhentcomparedtwithtothertfasttgrowingtStatestastwellt

astwithtoverallteconomictgrowthtoftthetIndianteconomy.tAlltthesetdynamictforcestfurther

tpressurizedtthetStatetfortmeagertallocationtoftfundsttotsocialtsectortintgeneraltandtpublict

healthtsectortintparticulartwhichtresultedtintfastertdesolationtoftpublicthealthtinfrastructure

tandtservices,tparticularlytintPunjab.

66
 CONCLUSIONt

Theteconomicttheorytstatestthattrisetintincometleveltoftentleadsttothighertstandardtoftlivingt

andtbetterthealthtoutcomes.tThetsteadytincreasetintthetpertcapitatincometoftthethouseholdtin

tPunjabthastatpositivetimpacttontlifetexpectancytattthettimetoftbirthtfortbothtmalestand

tfemales.tFortinstance,tint1981-

85tmaletexpectancytattthettimetoftbirthtwast58.5tyrstwhiletthattoftfemaletwast57.9tyrs.

tDuringt2013-

18tthetlifetexpectancytattthettimetoftbirthtist68.7tyrstfortmaletandt71.6tyrstfortfemale.

Itthastalsotbeentproventscientifically,tthattfemalestlivetlongertwhentcomparedtto

tmalestduettottheirtbiologicaltbodytstructure.tPunjabthastmarkedtsignificanttcontributiontin

tbringingtdowntcrudetbirthtratettot17.3tpertthousandtpeopletandtdeathtratettot7.2tper

tthousandtpeopletint2011.tHowever,tastfartastInfanttMortalitytRatet(IMR)tintPunjabtis

tconcernedtittiststilltontthethighertsidet(41tpertthousandtlivetbirths).tMaternaltMortalitytRate

t(MMR)tandtTotaltFertilitytRatet(TFR)tistalsotestimatedttotbetverythight(172tpertlakhtlive

tbirthtandt2.1tchildrentpertwoman).tAlthough,tPunjabtfarestbettertwhentcomparedttot

statisticstavailabletattalltIndiatleveltyettmuchtneededtworktistrequiredtintmaintainingt

adequatetdemographictindicators.

Nottonlytthis,ttheretiststilltatsignificanttgaptintotherthealthtamenitiestliketwatert

supplyt(pipedtwater,ttubetwelltetc.)tandtsanitationt(latrine,tseweragetsystem)tintPunjabtState.

tAlthough,tPunjabthastimprovedtsourcetoftdrinkingtwatertyettonlyt44tpercenttoftthetpiped

twatertreachestintotplot/yard.tTotmaketwatertpotable,tonlyt12tpercenttoftthethousehold

ttreatttheirtwater:touttoftwhicht3.7tpercenttboiltthetwater,t1tpercenttstraintwatertthrought

clothtandt5tpercentttreattintothertwaytandtremainingt88tpercenttdrinktwatertwithouttany

67
ttreatment:twheretast50tpercenttofthouseholdstintPunjabthavetimprovedtsanitationtfacilityt

whereastalmostt50tpercenttdotnotthavetpropertsanitationtfacility.''

IttmaytbetnotedtheretthattStatestliketWesttBengal,tKerala,tandtPunjabtintspitetoft

theirtsocio-

economictachievementthavetrecordedtthethighesttmorbiditytprevalencetintIndia.tOntthe

totherthand,tthosetwhichtaretsocio-

economicallytbackwardtStatestliketRajasthan,tMadhyatPradesh,tandtBiharthavetreportedtlow

esttmorbiditytrate.tAvailabletliteraturetintthetfieldtshowstthattthetvariationtintthetmorbidity

tprevalencetratetacrosstthetStatestcantbetduettotdifferencetintagetstructure,taccessibilitytoft

healthtservices,tsocio-

economictbackgroundtortcantbetduettotepidemiologicttransitiontortchangetintdiseasetprofilet

oftthetpopulationtetc.

Itthastbeentexaminedtfromtthetdatatthattdiseases/ailmentstliketfevertoftunknown

torigin,trespiratorytincludingtnosetandtthroat,tothertdiagnosedtailments,tdiarrheatand

hypertensiontemergedtastthettoptfivetcommontchronictdiseasestsufferedtbytthetpeopletof

tPunjabtbothtintruraltandturbantareas.tFurther,tmorbiditytpatterntsuggeststthattittistnottthe

tlifetstyletdiseases,tbuttdiseasestwhichtaretmoretcommunicabletintnaturetandtgenerallyt

acquiredtfromtcontaminatedtwatertandtpoortsanitationtaretthetmajortkillerstintPunjab.tTheret

istalsotatmismatchtbetweentthetdiseasetcontroltprogramstandtmorbiditiestintthetStatetandtme

dicinestsuppliedtintthetState.tThetgovernmenttmustttherefore,timprovetthetavailabilitytof

tessentialtdrugstandtalsotmusttrealizetthetimportancetoftbasictsanitationtandtsafetandtclean

tdrinkingtwater.

Hence,tittistcorrectttotsuggesttheretthatthealthytHavingtiststilltatdistanttdreamtinPunjab.

DISEASEtBURDENtINtPUNJAB
68
Datatpresentedtshowstthattint2018tastmanytast2,89,65,970personstreceivedttreatmenttintthet

OPD,t8,56,386tpersonstweretadmittedtforttreatmenttandt12695tdied.tThetleadingtcausetof

deathtamongthospitalizedtpatientstwastrelatedtotthetproblemstoftthetcirculatorytsystem,

tfollowedtbytinfectivetandtparasiticdiseases,tdiseasestoftthetrespiratorytsystem,texternal

tcauses,tinjury,tpoisoningtandconsequencestoftexternaltinjuries.

Togethertthesetfivetdiseasestaccounttfort70tpercenttoftdeathstamongtindoortpatients.

tRespiratorytsystemtrelatedtdiseasestaretthethighesttfortoutpatientttreatment.tOthertmajor

tcausestincludetabnormaltlaboratorytandtclinicaltfinding,tskintandtsubtcoetaneousttissue,t

digestivetsystem,tinfectivetandtparasitictdisease,tbloodtandtbloodtfonningtdisease,twhich

ttogethertaccounttfortaroundt65tpercenttoftthosetseekingttreatment.^

HEALTHtDELIVERYtSYSTEMtINtPUNJAB

IntPunjab,tbothtthetpublictsectortandtthetprivatetsectortplaystatpivotaltroletintthet

deliverytofthealthcaretservices.tIttistthetDepartmenttoftHealthtandtFamilytWelfaretundertthet

publictsectortwhichtistresponsibletfortprovidingtcurativetandtpreventivethealthcaretservices

tintPunjab.tTheoretically,ttheretistatfourttiertstructuretoftpublicthealthcaretdeliverytsystemtin

tthetState.t

Furthermore,tdistrictthospitalstfunctiontastatsecondaryttiertfortruralthealthcaretandt

primaryttiertforttheturbantpopulation.tTotsupporttthetsecondarythealthcarettheretistthe

ttertiarytlevelthealthcaretwhichtdealstwithtmoretcriticaltcasestthroughtcentraltgovernment

thospitalstandtmedicaltcollegestwhichtnottonlytprovidespecializedtandtdiagnostictfacilities

tbuttalsotcarrytouttresearchtandtdevelopmenttprogrammes.

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