JANUARY
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INDIA Private health insurance: The majority of private expenditures are out-of-pocket payments made mainly at the point of service, and less than 5 percent are financed by voluntary health insurance (VHI). Despite tax exemptions for insurance premiums, only upper-class urban populations are able to afford VHI, which serves as a substitute for government health services. Given India’s expanding middle class, low VHI penetration is surprising. It appears that in the coming years, the private insurance industry, which is still in its infancy, has the potential to expand. What is covered? Services: Covered services, some of which require copayments (see below), include preventive and primary care, diagnostic services, and outpatient and inpatient hospital care. Medications on the essential drug list are free (if and when available), while other prescription drugs are purchased from private pharmacies. Services available through the national health programs are free to all. India has one of the world’s largest publicly financed HIV drug programs, and all drugs and diagnostic services for vector-borne diseases, such as dengue fever and malaria, are free, as are insecticide-treated bed nets for malaria control. Immunizations and maternal and child health (MCH) services are free as well (MOH, 2014). Under the National Rural Health Mission, public health institutions in rural areas are being upgraded to meet the benchmarks for quality laid down by the Indian Public Health Standards (IPHS) (MOH 2013), which specify essential and desirable services that must be available in each type of health care facility. For example, at primary health centers these include outpatient services; emergency care provided mainly by nursing staff; referral and inpatient services; MCH-related services; school health and adolescent health services; care for noncommunicable diseases; basic laboratory services; linkages with secondary care providers and community health centers; basic surgical procedures; and medications on the state essential drug list and those required under national programs. The standards also cover necessary infrastructure and human resources. In practice, however, the availability of staff, equipment, and drugs varies significantly between and within states. Cost-sharing and out-of-pocket spending: Most states have some user charges for outpatient visits, hospital admission, diagnostic and prescription drugs, though there is huge variation in fee policies among the states. More than 70 percent of total health expenditures are financed through user fees, and most out-of-pocket spending is for hospital admissions. Nearly all admission, even to public hospitals, lead to catastrophic health expenditures, and over 63 million people are faced with impoverishment every year because of health care costs. In 2011–12, out-of-pocket spending on health care as a share of total monthly household spending per capita was 6.9 percent in rural areas and 5.5 percent in urban areas (MOH, 2014). Under the National Rural Health Mission, free treatment in public hospitals, as part of the Janani Suraksha Yojana, 1 was extended to maternity, newborn, and infant care and to control of tuberculosis, malaria, and HIV/ AIDS. For all other services, user fees continue to apply, especially for diagnostics and drugs excluded from the state’s essential drug list (MOH, 2014). Safety nets: Safety nets for the poor and other vulnerable groups are provided by a number of governmentfunded health insurance schemes that have been introduced in recent years. These are intended to improve access to hospitals and reduce out-of-pocket payments. Some states finance hospital care through health insurance programs. The RSBY (see above) protects mostly those below the poverty level. 2 Evaluations of such schemes show improved utilization of hospital services (mainly private), especially among the poorest 20 percent of households (MOH, 2014). 1 Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission with the objective of reducing maternal and neonatal mortality through the promotion of institutional delivery among poor pregnant women. 2 Defined as monthly per capita consumption expenditure of INR972 (USD55) in rural areas and INR1,407 (USD79.50) in urban areas. Please note that, throughout this profile, all figures in USD were converted from INR at a rate of INR17.7 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for India. The poverty ratio at the all-India level is 29.5 percent (Planning Commission, 2014). 78 The Commonwealth Fund
INDIA Another program, designed to reduce maternal mortality, is Janani Shishu Suraksha Karyakarm, launched in 2011 and currently implemented all over India. It entitles all pregnant women to free delivery, including by caesarean section, in public health institutions. Women receive free food, drugs, and consumables, as well as free diagnostics. Free transportation is also provided. Similar entitlements are available for all sick infants (up to age 1) at public health facilities (MOH, 2015a). How is the delivery system organized and financed? The average number of patients seen by a registered doctor and nurse is 1,212 and 532, respectively (WHO, 2013). This implies an average of 0.7 doctors and 1.1 nurses per 1,000 population, compared with 3.2 and 8.8, respectively, in countries within the Organisation for Economic Co-operation and Development (OECD, 2014). Although India has a much younger population than OECD countries, this acute shortage of providers is a major constraint as India moves toward universal coverage. Health care services are delivered by a complex network of public and private providers, ranging from single doctors to specialty and “super-specialty” tertiary care corporate hospitals. The government health care system is designed as a three-tier structure comprising primary, secondary, and tertiary facilities. Primary care: Facilities at the primary level include: subcenters (SCs), for a population of 3,000 to 5,000; primary health centers (PHCs), for 20,000 to 30,000 people; and community health centers (CHCs), which serve as referral centers for every four PHCs, covering 80,000 to 120,000. Primary health centers (PHCs) are the cornerstone of rural health services, serving as a first “port of call” to a qualified doctor in the public health sector and providing a range of preventive, promotive, and curative health services. On average, they have about six beds for inpatient admission. In 2012, there were 148,366 SCs, 24,049 PHCs, and 4,833 CHCs (CBHI, 2013). Availability of staff in these primary care facilities is a major concern. For example, specialist shortage at CHCs is nearly 70 percent (CBHI, 2013). Primary care doctors working in the public sector are employed by local governments and paid salaries. No registration is required, and patients generally go to the nearest PHC located in their geographical area. There are a number of other staff at PHCs, among them auxiliary nurse-midwives, pharmacists, and lab technicians— all on salary. Normally, there is limited scope for primary care doctors to earn additional income via incentives. Although government doctors in most states are banned from private practice, officials find it is difficult to monitor and take action against offending doctors. In the private sector, an array of services is provided, in both urban and rural areas, by solo practices ranging from unregistered “quacks” to registered medical practitioners to small nursing homes and poly clinics. There are estimates that as much as 40 percent of private care is provided by unqualified providers (MOH, 2014). Patients pay out-of-pocket for the services received. There are no fee schedules. Outpatient specialist care: In government health facilities, salaried, full-time specialists are located at CHCs and district hospitals. Usually, choice is limited in rural areas. These specialists are not permitted to work in private practice in most states. In the private sector, there is a huge choice of specialists, especially in urban areas. Consultation fees vary, as there is no fixed fee schedule, and they operate from their own clinics, hospitals, or poly clinics, or from speciality hospitals. Private specialists are commonly visited by upper- and middle-class urban residents. Administrative mechanisms for direct patient payments to providers: There are no direct payments in public health facilities and most government-sponsored insurance programs. In the private sector, patients usually pay directly out-of-pocket. Only in a small percentage of cases where patients have VHI is payment made up front and claims submitted to the insurer for reimbursement. After-hours care: All PHCs are expected to provide basic emergency services (mainly by nursing staff), and all CHCs are equipped to provide emergency services around-the-clock. Primary care doctors are required to International Profiles of Health Care Systems, 2015 79
- Page 28 and 29: CANADA provides recommendations to
- Page 30 and 31: CANADA Health Council of Canada (20
- Page 32 and 33: CHINA Private health insurance: Com
- Page 34 and 35: CHINA is not substantially more exp
- Page 36 and 37: CHINA Organization of the Health Sy
- Page 38 and 39: CHINA References Chen, X. (2014).
- Page 40 and 41: DENMARK In addition, nearly 1.5 mil
- Page 42 and 43: DENMARK Social psychiatry and care
- Page 44 and 45: DENMARK Quality data for a number o
- Page 46 and 47: DENMARK portion is small, it makes
- Page 48 and 49: 48
- Page 50 and 51: ENGLAND immunization, and vaccinati
- Page 52 and 53: ENGLAND Hospitals: Publicly owned h
- Page 54 and 55: ENGLAND Organization of the Health
- Page 56 and 57: ENGLAND How are costs contained? Ra
- Page 58 and 59: ENGLAND Organisation for Economic C
- Page 60 and 61: FRANCE VHI finances 13.8 percent of
- Page 62 and 63: FRANCE The average income of primar
- Page 64 and 65: FRANCE What are the key entities fo
- Page 66 and 67: FRANCE inequities in prevention rel
- Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
- Page 70 and 71: GERMANY There were 42 substitutive
- Page 72 and 73: GERMANY The 16 state governments de
- Page 74 and 75: GERMANY management system, by the s
- Page 76 and 77: GERMANY What major innovations and
- Page 80 and 81: INDIA provide after-hour care, reim
- Page 82 and 83: INDIA are provided by other ministr
- Page 84 and 85: INDIA How are costs contained? Ther
- Page 86 and 87: 86
- Page 88 and 89: ISRAEL Together, these two types of
- Page 90 and 91: ISRAEL Primary care physicians are
- Page 92 and 93: ISRAEL Organization of the Health S
- Page 94 and 95: ISRAEL • Using electronic health
- Page 96 and 97: 96
- Page 98 and 99: ITALY during hospitalization (Thoms
- Page 100 and 101: ITALY Some regions are promoting ca
- Page 102 and 103: ITALY Organization of the Health Sy
- Page 104 and 105: ITALY although the degree of evolut
- Page 106 and 107: ITALY The author would like to ackn
- Page 108 and 109: JAPAN What is covered? Services: Al
- Page 110 and 111: JAPAN incentives for providers to c
- Page 112 and 113: JAPAN Organization of the Health Sy
- Page 114 and 115: JAPAN The author would like to ackn
- Page 116 and 117: THE NETHERLANDS receive faster acce
- Page 118 and 119: THE NETHERLANDS Hospital payment ra
- Page 120 and 121: THE NETHERLANDS Organization of the
- Page 122 and 123: THE NETHERLANDS References Organisa
- Page 124 and 125: NEW ZEALAND provided in GP clinics.
- Page 126 and 127: NEW ZEALAND management (e.g., clean
INDIA<br />
Another program, designed to reduce maternal mortality, is Janani Shishu Suraksha Karyakarm, launched in<br />
2011 and currently implemented all over India. It entitles all pregnant women to free delivery, including by<br />
caesarean section, in public health institutions. Women receive free food, drugs, and consumables, as well as<br />
free diagnostics. Free transportation is also provided. Similar entitlements are available for all sick infants (up<br />
to age 1) at public health facilities (MOH, 2015a).<br />
How is the delivery system organized and financed?<br />
The average number of patients seen by a registered doctor and nurse is 1,212 and 532, respectively (WHO,<br />
2013). This implies an average of 0.7 doctors and 1.1 nurses per 1,000 population, compared with 3.2 and 8.8,<br />
respectively, in countries within the Organisation for Economic Co-operation and Development (OECD, 2014).<br />
Although India has a much younger population than OECD countries, this acute shortage of providers is a<br />
major constraint as India moves toward universal coverage.<br />
Health care services are delivered by a complex network of public and private providers, ranging from single<br />
doctors to specialty and “super-specialty” tertiary care corporate hospitals. The government health care<br />
system is designed as a three-tier structure comprising primary, secondary, and tertiary facilities.<br />
Primary care: Facilities at the primary level include: subcenters (SCs), for a population of 3,000 to 5,000;<br />
primary health centers (PHCs), for 20,000 to 30,000 people; and community health centers (CHCs), which serve<br />
as referral centers for every four PHCs, covering 80,000 to 120,000. Primary health centers (PHCs) are the<br />
cornerstone of rural health services, serving as a first “port of call” to a qualified doctor in the public health<br />
sector and providing a range of preventive, promotive, and curative health services. On average, they have<br />
about six beds for inpatient admission. In 2012, there were 148,366 SCs, 24,049 PHCs, and 4,833 CHCs (CBHI,<br />
2013). Availability of staff in these primary care facilities is a major concern. For example, specialist shortage at<br />
CHCs is nearly 70 percent (CBHI, 2013).<br />
Primary care doctors working in the public sector are employed by local governments and paid salaries. No<br />
registration is required, and patients generally go to the nearest PHC located in their geographical area. There<br />
are a number of other staff at PHCs, among them auxiliary nurse-midwives, pharmacists, and lab technicians—<br />
all on salary. Normally, there is limited scope for primary care doctors to earn additional income via incentives.<br />
Although government doctors in most states are banned from private practice, officials find it is difficult to<br />
monitor and take action against offending doctors.<br />
In the private sector, an array of services is provided, in both urban and rural areas, by solo practices ranging<br />
from unregistered “quacks” to registered medical practitioners to small nursing homes and poly clinics. There<br />
are estimates that as much as 40 percent of private care is provided by unqualified providers (MOH, 2014).<br />
Patients pay out-of-pocket for the services received. There are no fee schedules.<br />
Outpatient specialist care: In government health facilities, salaried, full-time specialists are located at CHCs<br />
and district hospitals. Usually, choice is limited in rural areas. These specialists are not permitted to work in<br />
private practice in most states. In the private sector, there is a huge choice of specialists, especially in urban<br />
areas. Consultation fees vary, as there is no fixed fee schedule, and they operate from their own clinics,<br />
hospitals, or poly clinics, or from speciality hospitals. Private specialists are commonly visited by upper- and<br />
middle-class urban residents.<br />
Administrative mechanisms for direct patient payments to providers: There are no direct payments in<br />
public health facilities and most government-sponsored insurance programs. In the private sector, patients<br />
usually pay directly out-of-pocket. Only in a small percentage of cases where patients have VHI is payment<br />
made up front and claims submitted to the insurer for reimbursement.<br />
After-hours care: All PHCs are expected to provide basic emergency services (mainly by nursing staff), and all<br />
CHCs are equipped to provide emergency services around-the-clock. Primary care doctors are required to<br />
International Profiles of Health Care Systems, 2015 79