India’s public health care system may have a problem. Earlier this week, the government slashed its $5 billion annual health care budget by a fifth, almost certainly straining a system that is creaking at the core and on which the country already spends an abysmally low amount.

India spends just 1.3 percent of its Gross Domestic Product (GDP) on public health care, and even including expenditure on private health care, the figure stands at 4.3 percent. Comparative data show that in terms of health care expenditure as a percentage of GDP, India significantly lags behind Brazil, Russia, China and South Africa, countries that are typically lumped together in the so-called BRICS bloc.

The Narendra Modi-led Bharatiya Janata Party (BJP) government faces fiscal constraints, necessitating the cut. The Modi government is facing a tax-revenue deficit of as much as one trillion rupees ($15.7 billion), forcing it to cut back on expenditure to meet its fiscal deficit target of 4.1 percent. However, this is not the first time that this has happened. In the previous fiscal year, the Congress party-led United Progressive Alliance (UPA) regime, under the premiership of Manmohan Singh, too had pruned the health budget by a similar amount.

But apart from the sagging economy, this cut in health expenditure could be an indicator of problems in financial management in the health ministry. Data from the Indian finance ministry’s mid-year analysis show that until September this year, the country’s health ministry had spent just about 42 percent, or less than half of the funds allocated to it in the annual budget. Proportionally, this is even less than the 48 percent it had spent in the same period last year when the Congress-led regime was in power.

The government’s own rules prohibit ministries from spending over 33 percent or one-third of their annual allocations in the last quarter of the financial year (January to March). This means that if a ministry wishes to exhaust its allocated funds, it has to spend at least two-thirds of its allocation between April and December of a financial year, failing which its spending would be restricted.

When the government does not spend enough, the citizen must. Typically, personal health care costs involve the cost of medical care (including hospitalization) and the cost of medicines. Government data from 2011 to 2012 show that while 80 percent of the non-hospitalization medical expenditure was on medicines in urban areas, the figure for rural India was 75 percent.

http://www.ibtimes.com/india-health-budget-did-lower-tax-receipts-lack-spending-force-india-cut-back-1767460

On Oct. 10, the government of India announced an ambitious new policy to provide universal mental health services. The policy, the country’s first on mental health, is admirable for its focus on the needs of the country’s poor, on lifting widespread stigma around mental health disorders and on preventing suicide. A bill to make the new policy law is awaiting approval by Parliament.

India has the highest number of suicides in the world. According to the World Health Organization, of 804,000 suicides recorded worldwide in 2012, 258,000 were in India. Indian youths between 15 and 29 years old kill themselves at a rate of 35.5 deaths per 100,000 — the highest in the world — and suicide has surpassed maternal mortality as the leading cause of death of young Indian women. A report from Human Rights Watch released in December exposed the horrific conditions in institutions where too many Indian women with mental and intellectual disabilities are confined, many against their will, and where some are subject to physical and sexual abuse and electric-shock therapy.

Unfortunately, the new policy may be almost impossible to translate into action. On Dec. 23, the government ordered cuts in the health budget of nearly 20 percent, from $5 billion to a little more than $4 billion. Given other serious health needs, the “fresh funds” promised by the government to pay for new mental health services and train qualified mental-health professionals are unlikely to materialize.

This is a pity. There is only one psychiatrist for every 343,000 Indians currently, too few to reduce the shameful suicide rate. Among other problems are depression, acute economic insecurity, anxiety among youths over educational success, and distress among young women caught in a bind between the opportunities of a changing India and pressure from traditionally minded families to marry.

Unless Prime Minister Narendra Modi reverses course, his impressive new policies will end up exactly like the development projects of the past administrations he excoriated during his campaign: high-minded pronouncements on paper with zero delivery in practice.

http://www.nytimes.com/2014/12/31/opinion/indias-mental-health-crisis.html?_r=0

The Union government plans to introduce a health cess to develop primary or basic healthcare infrastructure across the country.

This is mentioned in the National Health Policy 2015 draft put up on the ministry of health website on Wednesday for suggestions from public.

…

The draft policy suggests the cess may be drawn from general taxation as well as “specific commodity taxes” such as those on tobacco and alcohol. Some industries that have a negative impact on natural habitats or result in displacement, too, may be asked to pay health cess.

…

Public health experts, though, were unhappy with the draft policy saying it is vague on contentious issues such as the role of private healthcare providers and ways to fund healthcare for economically backward.

“The document sounds good, but it doesn’t emphasize commitment. For instance, it says the government will aim to reduce the common man’s out-of-pocket expenditure but doesn’t say by how much and by when,” said Dr Abhay Shukla of Jan Swasathya Abhiyan, a national coalition of NGOs in healthcare sector. “Considering that the Union government slashed the health budget last week, one wonders if this document is a mere decorative piece.”

National Health Policy Draft 2015 comes up almost 12 years after the last such plan, citing three main reasons—changing health needs, government’s inadequate healthcare expenditure and high out-of-pocket expenditure by people.

…

While non-communicable diseases account for 39.1% of India’s ill-health burden, the draft points out that conditions such as cancer and heart problems are not covered too well in the public health system. Communicable diseases account for 24% of India’s disease burden. Most of them, almost 75%, too, are not part of any existing national programmes.

Noting that families are driven to bankruptcy by healthcare expenditure, the draft said around 6.9% of the household monthly per capita expenditure in rural areas and 5.5% in urban areas is spent on healthcare.

http://timesofindia.indiatimes.com/india/Centre-plans-a-cess-for-basic-healthcare/articleshow/45709245.cms

Some 503,142 toilets have been installed in households across India since October, when Prime Minister Narendra Modi first announced Clean India Mission, a sanitation campaign that aims to eliminate open defecation by 2019.

It’s an ambitious and necessary target. According to the World Health Organization, more than 620 million people—about half India’s population—relieve themselves in the open, a practice with serious negative impacts on public health, safety, and the economy.

India has a lot more to overcome than just a mass installation of toilets and latrines. In a recent survey of 3,200 rural households by Delhi-based Research Institute for Compassionate Economics, half of respondents who didn’t have a toilet believed that “defecating in the open is the same or better for health than using a latrine.” Most people who owned a government-constructed latrine still chose to use the outdoors. Some end up using their loo for storage or extra living space.

Modi’s administration announced Wednesday that sanitary inspectors will soon be going door-to-door to “check and verify the use of toilets,” using tablets or phones to publish results online in “real time,” according to a press release. “Earlier, the monitoring was done only about the construction of toilets, but now the actual use of toilets will be ascertained.”

That’s a lot of resources devoted to an approach with little in the way of precedent. Could it really work?

John Oldfield, CEO of WASH Advocates, a nonprofit that advocates for safe drinking water and sanitation, stresses there’s no silver bullet when it comes to solving a sanitation crisis. “Most importantly, I think one needs to take a more holistic look at this problem,” he says. “Change has to be demand-driven. People have to want to use toilets, not have them forced upon them.”

Oldfield suggests that inspections might be useful in that they might pressure or even “shame” citizens into using their toilets. “It could sort of be like neighbors spying on each other to see who’s defecating out in the open,” he says.

Others have warned that public outreach and educational campaigns should figure much more prominently in Clean India’s strategy. Only 8 percent of the $30 billion dedicated to the mission is marked for “information, education and communication.”

“I would spend at least half of the money on IEC,” Santosh Mehrotra, an economics professor at New Delhi’s Jawaharlal Nehru University, told the Wall Street Journal.

http://www.citylab.com/design/2015/01/indias-government-will-now-check-and-verify-the-use-of-toilets/384174/

Ram Lakshmanan and his team were onstage at the Clinton Global Initiative annual meeting in New York on Tuesday evening. They were finalists for the Hult Prize, which each year awards $1 million to the best plan for addressing global problems. They were making their pitch for a better healthcare plan that would include something they’re calling “Doc-in-a-Box.”

…
This year’s prize challenge focused on proposals to improve life for the 250 million people living in slums and suffering from chronic diseases like diabetes, high blood pressure and heart disease. Slum dwellers often can’t afford medical care or live too far away to reach clinics. The care they can obtain often focuses on emergency services rather than long-term health.
…

The winning project, called NanoHealth, proposes hiring and training community health workers, and equipping them with “Doc-in-a-Box,” a diagnostic tool the team designed that can measure basic indicators like blood sugar, blood pressure and blood lipids and create an electronic health record for the patient.

The health workers are called saathi [friend], and are hired from the community, trained and certified by the organization. They run screening camps to diagnose patients and refer them to partner healthcare organizations, and then follow up with the patients frequently to make sure they are taking their medicines or implementing lifestyle changes.

The team originally conceived a narrower project, simply to help slum dwellers with chronic diseases stick to their prescription plans. But the students quickly discovered that many patients didn’t know what medicines they were supposed to take — if they had even been diagnosed.

“Let’s get some doctors to verify their diagnosis,” Aditi Vaish, 35, remembers thinking. “But no doctors serve these slums. So let’s get a screening device.” Once they’d conceptualized the Doc-In-A-Box, they decided to set up “camps” in the slums to meet with the residents and get their medical information.

Of necessity, their project became more holistic. “One part was not enough,” says Ashish Bondia, 32. “For the urban slum dweller, the entire healthcare journey was missing.”

“In order to have an impact in chronic care, whether that is in an urban slum or for anyone, you need to treat all the pieces of the problem,” adds Vaish. “There’s underdiagnosis, poor treatment and poor compliance.”
http://www.npr.org/blogs/goatsandsoda/2014/09/26/351515298/and-the-million-dollar-hult-prize-goes-to-a-doc-in-a-box