Developments in Health Sector of Rajasthan economyRajasthan is the largest state of India, positionedin the north-western region of the country. It embodies 11% of the totalgeographical surface of the country equaling to 342,239 square km. Thepopulation of Rajasthan as per the census of 2011 is 6.86 crore.
Topographically Aravali Range separates Rajasthan into 2geographical zones – desert on one side and forests on the other. Populationdensity differs with the desert region having 60-80 people per square km andother areas up to 200 people per square km. 10 High Priority Districts & 6Tribal Districts (3 under HPD) have been identified in Rajasthan based on lowercomposite health index.STATUSOF HEALTH INDICATORS-RAJASTHAN1. Infant Mortality Rate: 41 inNFHS-412. Under 5 Mortality Rate: 51 inNFHS 4 3. Maternal Mortality Rate: 244 in SRS 2011-13 4.
Sex Ratio – Sex Ratio at birth:887 in NFHS 4 5. Literacy Rate: 67.06 % inCensus 20116. Age at Marriage: 20—24 years women married before 18 years: (35.4%)7. Full immunization: 74.
2% in AHS2012, 8. Total Fertility Rate: 2.4 inNFHS 4 9. Institutional Births: 84% inNFHS 4 10. Children under age 6 months exclusively breastfed: 58.2% in NFHS 4 11.
Rajasthan has reported percentage of Underweight (Weight for age) ofunder five children is 36.7% in 2015-16(30.7% in urban areas and 38.41% inrural areas) 12. Percentage of stunted (height for age) under five children are 39.
1%in 2015-16(33% in urban areas and 40.8% in rural areas)13. Percentage of wasted (weight for age) under five children is 23% in2015-16(21.6%in urban areas and 23.4% in rural areas) 14.
Percentage of anemia in 60.3% children aged 6-59 months (<11.0g/dl) in 2015-16, (55.7% in urban areas and 61.
6% in rural areas)15. Percentage of anemia in non-pregnant women aged 15-49 years(<12.0 g/dl) is 46.8% in 2015-16, it is 40.7% in urban areas and 49.0% inrural areas. 16.
Percentage of anemia in Pregnant women aged 15-49 years (<11.0g/dl) is 46.6% in 2015-16( 41.4% in urban areas and 48.
0% in rural areas ) RajasthanGovernment has implemented various inventiveness and schemes with the supportof latest technology which have contributed to a dignified rise in the healthindex of the people in the state. The Government has opened gates for theprivate players to invest in the state. The Government is working withPublic-Private- Partnership (PPP) to provide proper healthcare delivery to womenand childen, and improving the nutrition status. Governments plans to run aPrimary Health Centre (PHC), CT scan and MRI, Hemodialysis in districthospitals, cancer care units in 17 district hospitals, IVF center in districthospitals under Public-Private- Partnership (PPP). However, the state has totake long strides so as to meet SDG goals by 2030. Thetopography of the State with a dispersed population presents a challenge foraccess to healthcare especially in Thar and Bhil zones. Some other challengingareas are Rural/ Urban Disparities in Health scenario, Shortage of staff,Reluctance of staff to work in rural areas, Influence of quacks, myths,misconceptions resulting from lower literacy, increasing burden of lifestylediseases, challenge of skewed sex ratio due to sex-selective abortions ,continuedneglect and poor health care-seeking for the girl child.
Reasons being desireof male child, dowry system, social customs, lack of educational status ofwomen and empowerment. Rajasthan falls under the category of high prioritystate, due to its poor socio-development indicators, particularly in the areasof family planning, MCH and Nutrition. Rajasthan is highly affected bymalnutrition with an under 5 mortality rates of 51. State has high fertility rate, looking at the fertilitydynamics of the state the Centre has identified 14 districts namely Dholpur,Karauli, SawaiMadhopur, Bharatpur, Udaipur, Dungarpur, Rajsamand, Banswara,Jalore, Barmer, Jaisalmer, Pali, Baran and Sirohi.
for intensive and improvedfamily planning services.Looking at theachievements of NHP 2002 and Millennium Development Goals with respect topopulation stabilization, disease control program, and inequities in healthoutcomes and quality of care, India’s performance has been a few notches belowthe target levels with respect to Infant mortality rate (IMR), Maternalmortality ratio (MMR), and Under-5 mortality rate (U5MR). NHP 2002, actually missedon the requirement to address the whole range of current health problems, andthe social, economic and ecological determinants of health. In the NHP 2017,all elements of Health Policy Triangle as framed by Walt and Gilson in 1994have been considered. Like a good cake needs right kind of ingredients, sameway Draft National Health Policy was reviewed by various actors that includedhealth ministers of various States, NGOs, civil society participation,representation of private sector. However, the Government has no consideration tomake health as a fundamental right. National Health Policy, 2017 advocatesprogressively incremental Assurance based Approach with focus on preventive andpromotive healthcare.
Need of hour is what Rajasthan has to look at in newpolicy that leads us to understand that is futuristic as described by Hon’blePrime Minister, Shri Narendra Modi in his tweet but before that need to look atcomparatives of the Goals as per NHP-2002,NHP-2017and SDG S. No. Health Indicator NHP 2002 NHP 2017 SDG India 1 Increase Life Expectancy 64.6 achieved till 2000 67.
5 to 70 by 2025 2 TFR 2.1 by 2012 2.1 by 2025 at all levels Reduction of TFR to 2.1 3 IMR 30 by 2012 28 by 2019 Reduction IMR to 19 4 U-5 mortality NA 23 by 2025 25 5 MMR 100/Lakh by 2010 100 by 2025 Reduction of MMR to 75 by 2017 6 NMR 16 by 2025 7 Elimination of Leprosy & Kala-Azar, Lymphatic Filariasis By 2005, 2010, 2015 By 2018 & 2017 8 Reduce Prevalence of Blindness 0.50/1000 by 2010 0.25/1000 by 2025 Comparatives of the Goals as per NHP-2002,NHP-2017 and SDGThe NationalHealth Policy 2017 recognizes the need of better access, education andempowerment for effective population stabilization. The policy stresses to movefrom camp based approach of offering the family planning health services orimmunization services to make it available on all days or at least on a fixedday. NHP 2017, promises to cover the length and breadth of India reachingthe unreachable in providing quality healthcare to every citizen of India thusaddressing the key principal approach of policy formation that is Equality,Equity and affordability.
Among key targets, laid out by NHP 2017 and SDG arein Fig-1. Even though Government of Rajasthan has made intensive efforts toimprove on Maternal and child mortality yet to reach the SDG goals and met theindicators laid down in NHP -2017, the need is to accelerate the pace of decline.(Fig2 to Fig 5 ) show decline in mortality and fertility trends of Rajasthanand India.
Also, this should be kept in mind that there is large disparitybetween the rural and urban mortality indicators Besidesthis the policy looks at following indicators:Ø Decline in the premature mortality from NCDs -25% by 2025. Globaltarget of 90:90:90 for HIV/AIDS by 2020 Ø Reduce incidence of new cases of TB by 2025 and aim at Cure rate of (>85%)in new sputum positive patientsØ Increase of 50% in utilization of public health facilities by 2025Ø Ensuring skilled birth attendance and ANC care above 90% by 2025Ø Ensuring more than 90% of newborns are fully immunized by one yearof age (2025)Ø Addressing family planning need above 90% at national and subnational level by 2025.Ø 80% of known hypertensive and diabetic individuals at householdlevel maintain Ø Decrease in prevalence of tobacco use (15% by 2020 and 30% by 2025)Ø 40% reduction in prevalence of stunting of under-five children by2025Ø Under Swachh Bharat Mission, access to safe water and sanitation toall by 2020 Ø Decline in the health expenditure of households by 25% by 2025 Ø Ensure availability of paramedics and doctors as per Indian PublicHealth Standard (IPHS) norm in high priority districts by 2020 and establishingprimary and secondary care facilities in High priority districts.Ø Ensure district-level electronic database of information on healthsystem components by 2020Ø Strengthening the health surveillance system and ensuring district-levelelectronic database of information HealthFinance and Impact on Gross Domestic ProductThe policy recommendsenhancement of public health expenditure from 1.15% to 2.5 % of the GDP in atime-bound manner.
Earlier we have had experience of experiencing decline inpublic health investment as a percentage of GDP declined from 1.3% in 1990 to.9 percent in 1999. India’s public health spending is 1.16% of gross domesticproduct (GDP) while the World Health Organization (WHO) recommends spending 5%of GDP.
India has yet to go a long way to meet the 2010 target of spending of 2%of GDP on health, it has always been on the lower side while as Global meanhealth spending is around 5-6 %. But this is a very bold and pragmaticinitiative and will definitely reap dividends. The policy has also laid downincrease in state health spending upto >8% of their budget by 2020.Hence state should give tail wind to the followingpointers to achieve the indicators laid down by Health policy 2017 and SDGs areachieved.
o The need allocates strengthen primaryhealth care, ensure availability of two beds per 1,000 population, providecomprehensive primary healthcare services – including maternal and childhealth, nutrition services, CDs, NCDs, collaboration with National HealthProgrammes. o Address the high TotalFertility Rate (TFR) in HPDS by having availability family planning commoditiesand ensuring counselling.o Ensuring maternal nutritionbefore, during and after pregnancy. Ensuring balanced energy, protein, calcium,and multiple micronutrient supplementationo To address malnutrition andguaranteeing good healthy practices in children the practices followed shouldbe growth monitoring, exclusive breastfeeding and appropriate complementaryfeeding, full immunization, prophylactic iron supplementationo In addition to counselling offamilies; distribution of iron and folic acid (IFA) supplements to children aswell as mothers. This can be achieved through appropriate training to ASHAs,ANMs and Angan wadi workers.o Urgent need of having adequatestaff both clinical and administrative staff, functional equipment’s, medicinesand diagnostic tests.
o Well monitored centers (e.g.,doctor attendance/ Paramedical attendance).o Capacity building, supportivesupervision, onsite correction of gaps and hand holding of staff nurses,Medical officers and Pediatricians.o Uniform centers with deliveryprotocols, cleanliness / hygiene protocols, designated and approved IECmaterials, appropriate signage, uniform coloringo Grievance redressal mechanism,feedback systems gauge and enhance patient satisfaction and engage, empower thecommunity to drive accountabilityo Need to have a robust MISsystem with a common platform linking all the current information system whichwork in silos Patient focused systems: PCTS (NIC), Arogya (NIC), Raj eOffice (DoIT), ASHASoft (NIC), eAushadhi(CDAC), eUpkaran (CDAC).o MIS that encourage the use ofevidence-based medicine, guidelines, electronic prescribing in inpatient andoutpatient settings though the implementation of the EHR; this will, in time,encourage healthcare data collection, transparency, quality management, patientsafety, efficiency, efficacy and appropriateness of care.
o Transport availability forwhich people fail to access institutional health service.o Develop standard operatingmeasures for examination by which doctors, nurses and pharmacists are able topractice and get employment.o Ensuring that Hospitalsin the state get national accreditation in order to get paid by insurancecompanies. However, a performance incentive plan for those who address thequality and specific treatment parameters.o Looking at the provision of connecting withprivate insurance agencies so as to provide medical insurance coverage to thelarger populace. o Develop partnershipsbetween the line departments and private sectors players for better convergenceConclusion: Rajasthan, given its large population base anda diversified economy in mining, agriculture and tourism has shown significantprogress in improving governance and tackling high mortality indicators.
However, to meet SDG indicators the state should invest in the interventionsthat will help in accelerated decline population growth as well as reduce child,infant and maternal mortality. Measures should also be taken to reduce disparityof rural urban divide by chalking out strategies to address tribal and scatteredpopulation, interdepartmental convergence and involvement of PRIs in theplanning, implementation and monitoring process. The state should benefit from considerablegrowth in Public-Private Partnership (PPP) and Foreign Direct Investment (FDI)for the development of healthcare sector and adopt certain measures to meet therural and urban healthcare needs. Thus, there is a need of appropriate planningto reduce inter and intra district variations in educational and healthdevelopment, adopt a state-of-the-art platform for people, hospitals andhealthcare professionals [i]http://rchiips.org/NFHS/factsheet_NFHS-4.shtmlhttps://www.nhp.gov.in/sites/default/files/pdf/NationaL_Health_Pollicy.pdfhttp://18.104.22.168/showfile.php?lid=4275http://datatopics.worldbank.org/sdgatlas/SDG-03-good-health-and-well-being.html[i]Atlas of Sustainable Development Goals 2017[i] NATIONAL HEALTH POLICY – 2002[i] NATIONAL HEALTH POLICY, 2017[i]National family Health Survey-2014