Health

HEALTHCARE IN INDIA

The Indian Constitution makes the provision of healthcare in India the responsibility of the state governments, rather than the central federal government. It makes every state responsible for "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties".

NUTRITION

Nutrition is the science that interprets the nutrients and other substances in food in relation to maintenance, growth, reproduction, health and disease of an organism. It includes food intake, absorption, assimilation, biosynthesis, catabolism and excretion.

The diet of an organism is what it eats, which is largely determined by the availability and palatability of foods. For humans, a healthy diet includes preparation of food and storage methods that preserve nutrients from oxidation, heat or leaching, and that reduces risk of foodborne illnesses. The seven major classes of human nutrients are carbohydrates, fats, fiber, minerals, proteins, vitamins, and water. Nutrients can be grouped as either macronutrients or micronutrients (needed in small quantities).

In humans, an unhealthy diet can cause deficiency-related diseases such as blindness, anemia, scurvy, preterm birth, stillbirth and cretinism, or nutrient excess health-threatening conditions such as obesity and metabolic syndrome;and such common chronic systemic diseases as cardiovascular disease, diabetes, and osteoporosis. Undernutrition can lead to wasting in acute cases, and the stunting of marasmus in chronic cases of malnutrition.

STANDARD OF LIVING

An individual's or a socioeconomic class's standard of living is the level of wealth, comfort, material goods, and necessities available to them in a certain geographical area, usually a country. The standard of living includes factor as a whole quality and availability of employment, class disparity, poverty rate, quality and housing affordability, hours of work are required to purchase necessities, gross domestic product, inflation rate, amount of leisure time every year, affordable (or free) access to quality healthcare, quality and availability of education, literacy rates, life expectancy, occurrence of diseases, cost of goods and services, infrastructure, national economic growth, economic and political stability, freedom, environmental quality, climate and safety. The standard of living is closely related to quality of life.

Quality of life is the general well-being of individuals and societies, outlining negative and positive features of life. It consists of the expectations of an individual or society for a good life. These expectations are guided by the values, goals and socio-cultural context in which an individual lives. It serves as a reference against which an individual or society can measure the different domains of a personal life.[citation needed] The extent to which one's own life coincides with a desired standard level - or, put differently, the degree to which these domains give satisfaction and as such contribute to one's subjective well-being - is called[by whom?] life satisfaction.

Quality of life includes everything from physical health, family, education, employment, wealth, safety, security to freedom, religious beliefs, and the environment. QOL has a wide range of contexts, including the fields of international development, healthcare, politics and employment. Health related QOL (HRQOL) is an evaluation of QOL and its relationship with health.[3] Quality of life should not be confused with the concept of standard of living, which is based primarily on income.

Standard indicators of the quality of life include not only wealth and employment but also the built environment, physical and mental health, education, recreation and leisure time, and social belonging.According to the World Health Organization (WHO), quality of life is defined as “the individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals.” In comparison to WHO's definitions, the Wong-Baker Faces Pain Rating Scale defines quality of life as “life quality (in this case, physical pain) at a precise moment in time.”

Quantitative measurement

Unlike per capita GDP or standard of living, both of which can be measured in financial terms, it is harder to make objective or long-term measurements of the quality of life experienced by nations or other groups of people. Researchers have begun in recent times to distinguish two aspects of personal well-being: Emotional well-being, in which respondents are asked about the quality of their everyday emotional experiences—the frequency and intensity of their experiences of, for example, joy, stress, sadness, anger, and affection— and life evaluation, in which respondents are asked to think about their life in general and evaluate it against a scale.Such and other systems and scales of measurement have been in use for some time. Research has attempted to examine the relationship between quality of life and productivity.There are many different methods of measuring quality of life in terms of health care, wealth and materialistic goods. However, it is much more difficult to measure meaningful expression of one's desires. One way to do so is to evaluate the scope of how individuals have fulfilled their own ideals. Quality of life can simply mean happiness, the subjective state of mind. By using that mentality, citizens of a developing country appreciate more since they are content with the basic necessities of health care, education and child protection.

Human Development Index

Perhaps the most commonly used international measure of development is the Human Development Index (HDI), which combines measures of life expectancy, education, and standard of living, in an attempt to quantify the options available to individuals within a given society. The HDI is used by the United Nations Development Programme in their Human Development Report.

The Human Development Index (HDI) is a statistic composite index of life expectancy, education, and per capita income indicators, which are used to rank countries into four tiers of human development. A country scores a higher HDI when the lifespan is higher, the education level is higher, and the gross national income GNI (PPP) per capita is higher. It was developed by Pakistani economist Mahbub ul Haq and Indian economist Amartya Sen and was further used to measure a country's development by the United Nations Development Programme (UNDP)'s Human Development Report Office.

The 2010 Human Development Report introduced an Inequality-adjusted Human Development Index (IHDI). While the simple HDI remains useful, it stated that "the IHDI is the actual level of human development (accounting for inequality)", and "the HDI can be viewed as an index of 'potential' human development (or the maximum IHDI that could be achieved if there were no inequality)". The index does not take into account several factors, such as the net wealth per capita or the relative quality of goods in a country. This situation tends to lower the ranking for some of the most advanced countries, such as the G7 members and others.

The index is based on the human development approach, developed by ul Haq, often framed in terms of whether people are able to "be" and "do" desirable things in life. Examples include—Being: well fed, sheltered, healthy; Doing: work, education, voting, participating in community life. The freedom of choice is central—someone choosing to be hungry (as during a religious fast) is quite different from someone who is hungry because they cannot afford to buy food, or because the country is in a famine.

PUBLIC HEALTH

Public health has been defined as "the science and art of preventing disease”, prolonging life and improving quality of life through organized efforts and informed choices of society, organizations, public and private, communities and individuals.Analyzing the determinants of health of a population and the threats it faces is the basis for public health.The public can be as small as a handful of people or as large as a village or an entire city; in the case of a pandemic it may encompass several continents. The concept of health takes into account physical, psychological, and social well-being. As such, according to the World Health Organization, it is not merely the absence of disease or infirmity and more recently, a resource for everyday living.

Public health is an interdisciplinary field. For example, epidemiology, biostatistics, social sciences and management of health services are all relevant. Other important subfields include environmental health, community health, behavioral health, health economics, public policy, mental health, health education, occupational safety, gender issues in health, and sexual and reproductive health.

Public health aims to improve the quality of life through prevention and treatment of disease, including mental health. This is done through the surveillance of cases and health indicators, and through the promotion of healthy behaviors. Common public health initiatives include promotion of handwashing and breastfeeding, delivery of vaccinations, suicide prevention, and distribution of condoms to control the spread of sexually transmitted diseases.

Modern public health practice requires multidisciplinary teams of public health workers and professionals. Teams might include epidemiologists, biostatisticians, medical assistants, public health nurses, midwives, medical microbiologists, economists, sociologists, geneticists, data managers, and physicians. Depending on the need, environmental health officers or public health inspectors, bioethicists, and even veterinarians, gender experts, or sexual and reproductive health specialists might be called on.

Like in other nations, access to health care and public health initiatives are difficult challenges in developing countries. Public health infrastructures are still forming in those countries.

Background

The focus of a public health intervention is to prevent and mitigate diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments. Many diseases are preventable through simple, nonmedical methods. For example, research has shown that the simple act of handwashing with soap can prevent the spread of many contagious diseases. In other cases, treating a disease or controlling a pathogen can be vital to preventing its spread to others, either during an outbreak of infectious disease or through contamination of food or water supplies. Public health communications programs, vaccination programs and distribution of condoms are examples of common preventive public health measures. Measures such as these have contributed greatly to the health of populations and increases in life expectancy.

Public health plays an important role in disease prevention efforts in both the developing world and in developed countries through local health systems and non-governmental organizations. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. Most countries have their own governmental public health agency, often called the ministry of health, with responsibility for domestic health issues.

In the United States, state and local health departments are on the front line of public health initiatives. In addition to their national duties, the United States Public Health Service (PHS), led by the Surgeon General of the United States, and the Centers for Disease Control and Prevention, headquartered in Atlanta, are also involved with international health activities.

In Canada, the Public Health Agency of Canada is the national agency responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. The Public health system in India is managed by the Ministry of Health & Family Welfare of the government of India with state-owned health care facilities.

Education and training

Education and training of public health professionals is available throughout the world in Schools of Public Health, Medical Schools, Veterinary Schools, Schools of Nursing, and Schools of Public Affairs. The training typically requires a university degree with a focus on core disciplines of biostatistics, epidemiology, health services administration, health policy, health education, behavioral science, gender issues, sexual and reproductive health, public health nutrition, and environmental and occupational health.

In the global context, the field of public health education has evolved enormously in recent decades, supported by institutions such as the World Health Organization and the World Bank, among others. Operational structures are formulated by strategic principles, with educational and career pathways guided by competency frameworks, all requiring modulation according to local, national and global realities. It is critically important for the health of populations that nations assess their public health human resource needs and develop their ability to deliver this capacity, and not depend on other countries to supply it.

THE NATIONAL HEALTH POLICY

The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002, and then again updated in 2017.

The recent four main updates in 2017 mentions the need to focus on the growing burden of non-communicable diseases, on the emergence of the robust healthcare industry, on growing incidences of unsustainable expenditure due to health care costs and on rising economic growth enabling enhanced fiscal capacity. In practice however, the private healthcare sector is responsible for the majority of healthcare in India, and most healthcare expenses are paid directly out of pocket by patients and their families, rather than through health insurance. Government health policy has thus far largely encouraged private-sector expansion in conjunction with well designed but limited public health programmes.

A government-funded health insurance project was launched in 2018 by the Government of India, called Ayushman Bharat.

According to the World Bank, the total expenditure on health care as a proportion of GDP in 2015 was 3.89%. Out of 3.89%, the governmental health expenditure as a proportion of GDP is just 1%, and the out-of-pocket expenditure as a proportion of the current health expenditure was 65.06% in 2015.

Ayushman Bharat Yojana

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) is a part of the Indian government's National Health Policy which aims to provide free health coverage at the secondary and tertiary level to its bottom 40% poor and vulnerable population. PM-JAY is the world's largest and fully state sponsored health assurance scheme which covers a population of the combined size of USA, Mexico and Canada.
It was launched in September 2018, under the aegis of Ministry of Health and Family Welfare in India.

PM-JAY is a health assurance scheme that covers 10.74 crores households across India or approx 50 cr Indians.

It provides a cover of 5 lakh per family per year for medical treatment in empanelled hospitals, both public and private.

It provides cashless and paperless service to its beneficiaries at the point of service, i.e the hospital.

E-cards are provided to the eligible beneficiaries based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011).

There is no restriction on family size, age or gender.

All previous medical conditions are covered under the scheme.

It covers 3 days of hospitalisation and 15 days of post hospitalisation, including diagnostic care and expenses on medicines.

The scheme is portable and a beneficiary can avail medical treatment at any PM-JAY empanelled hospital outside their state and anywhere in the country.

The Central government has decided to provide free testing and treatment of Coronavirus under the Ayushman bharat yojna.

Reach

So far, 25 States and Union Territories have adopted the PM-JAY scheme, except three states: Odisha, West Bengal and Telangana, and Union territory Delhi By February 2020, more than 12 crore e-cards have been generated and over 86 lakh people have taken benefit under this scheme. The number of public and private hospitals empanelled nationwide stands at 22,000.

Challenges

The scheme has faced some challenges in its year and a half journey, mainly that of fraudulent medical bills.

There have been media reports of misuse of the Ayushman Bharat scheme by unscrupulous private hospitals through submission of fake medical bills. Under the Scheme, surgeries have been claimed to be performed on persons who had been discharged long ago and dialysis has been shown as performed at hospitals not having kidney transplant facility.

There are at least 697 fake cases in Uttarakhand State alone, where fine of Rs one crore has been imposed on hospitals for frauds under the Scheme. However, unlike the earlier RSBY (Rashtriya Swasthya Bima Yojana) era, plagued by lax monitoring of insurance fraud, AB-PMJAY involves a robust information technology infrastructure overseeing transactions and locating suspicious surges across the country. Many hospitals have been blacklisted and the constantly evolving fraud-control system will play a major role in streamlining the scheme as it matures.[citation needed] Initial analysis of high-value claims under PMJAY has revealed that a relatively small number of districts and hospitals account for a high number of these, and some hint of an anti-women bias, with male patients getting more coverage. Despite all efforts to curb foul-play, the risk of unscrupulous private entities profiteering from gaming the system is clearly present in AB-PMJAY.

Public healthcare

Public healthcare is free and subsidized for those who are below the poverty line.The Indian public health sector encompasses 18% of total outpatient care and 44% of total inpatient care. Middle and upper class individuals living in India tend to use public healthcare less than those with a lower standard of living. Additionally, women and the elderly are more likely to use public services. The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status or caste.However, reliance on public and private healthcare sectors varies significantly between states. Several reasons are cited for relying on the private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Much of the public healthcare sector caters to the rural areas, and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are long distances between public hospitals and residential areas, long wait times, and inconvenient hours of operation.

Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved. Interaction between the state and national governments does occur for healthcare issues that require larger scale resources or present a concern to the country as a whole.

Considering the goal of obtaining universal health care as part of Sustainable Development Goals, scholars request policy makers to acknowledge the form of healthcare that many are using. Scholars state that the government has a responsibility to provide health services that are affordable, adequate, new and acceptable for its citizens.Public healthcare is very necessary, especially when considering the costs incurred with private services. Many citizens rely on subsidized healthcare.The national budget, scholars argue, must allocate money to the public health sector to ensure the poor are not left with the stress of meeting private sector payments.

Following the 2014 election which brought Prime Minister Narendra Modi to office, the government unveiled plans for a nationwide universal health care system known as the National Health Assurance Mission, which would provide all citizens with free drugs, diagnostic treatments, and insurance for serious ailments.

In 2015, implementation of a universal health care system was delayed due to budgetary concerns. In April 2018 the government announced the Aayushman Bharat scheme that aims to cover up to Rs. 5 lakh to 100,000,000 vulnerable families (approximately 500,000,000 persons – 40% of the country's population).
This will cost around $1.7 billion each year. Provision would be partly through private providers.

Outpatient care or Ambulatory care

Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedures even when provided outside of hospitals.

Public ambulatory care facility in Maracay, Venezuela, providing primary care for ambulatory care sensitive conditions.

Ambulatory care sensitive conditions (ACSC) are health conditions where appropriate ambulatory care prevents or reduces the need for hospital admission (or inpatient care), such as diabetes or chronic obstructive pulmonary disease.

Many medical investigations and treatments for acute and chronic illnesses and preventive health care can be performed on an ambulatory basis, including minor surgical and medical procedures, most types of dental services, dermatology services, and many types of diagnostic procedures (e.g. blood tests, X-rays, endoscopy and biopsy procedures of superficial organs). Other types of ambulatory care services include emergency visits, rehabilitation visits, and in some cases telephone consultations.

Ambulatory care services represent the most significant contributor to increasing hospital expenditures and to the performance of the health care system in most countries, including most developing countries.

Inpatient care

Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure[citation needed] that patients are only admitted to a hospital when they are extremely ill or have severe physical trauma.

Patient

A patient is any recipient of health care services performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, psychologist, dentist, veterinarian, or other health care provider.

Healthcare

Health care, health-care, or healthcare is the maintenance or improvement of health via the prevention, diagnosis, treatment, recovery, or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, pharmacy, midwifery, nursing, medicine, optometry, audiology, psychology, occupational therapy, physical therapy, athletic training and other health professions are all part of health care. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Access to health care may vary across countries, communities, and individuals, influenced by social and economic conditions as well as health policies. Providing health care services means "the timely use of personal health services to achieve the best possible health outcomes".Factors to consider in terms of healthcare access include financial limitations (such as insurance coverage), geographic barriers (such as additional transportation costs, possibility to take paid time off of work to use such services), and personal limitations (lack of ability to communicate with healthcare providers, poor health literacy, low income).Limitations to health care services affects negatively the use of medical services, the efficacy of treatments, and overall outcome (well-being, mortality rates).

Health care systems are organizations established to meet the health needs of targeted populations. According to the World Health Organization (WHO), a well-functioning health care system requires a financing mechanism, a well-trained and adequately paid workforce, reliable information on which to base decisions and policies, and well maintained health facilities to deliver quality medicines and technologies.

An efficient health care system can contribute to a significant part of a country's economy, development, and industrialization. Health care is conventionally regarded as an important determinant in promoting the general physical and mental health and well-being of people around the world. An example of this was 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.

Delivery of healthcare

The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams.This includes professionals in medicine, psychology, physiotherapy, nursing, dentistry, midwifery and allied health, along with many others such as public health practitioners, community health workers and assistive personnel, who systematically provide personal and population-based preventive, curative and rehabilitative care services.

While the definitions of the various types of health care vary depending on the different cultural, political, organizational and disciplinary perspectives, there appears to be some consensus that primary care constitutes the first element of a continuing health care process and may also include the provision of secondary and tertiary levels of care.Health care can be defined as either public or private.

The emergency room is often a frontline venue for the delivery of primary medical care.

Primary care

Primary care refers to the work of health professionals who act as a first point of consultation for all patients within the health care system. Such a professional would usually be a primary care physician, such as a general practitioner or family physician. Another professional would be a licensed independent practitioner such as a physiotherapist, or a non-physician primary care provider such as a physician assistant or nurse practitioner. Depending on the locality, health system organization the patient may see another health care professional first, such as a pharmacist or nurse. Depending on the nature of the health condition, patients may be referred for secondary or tertiary care.

Primary care is often used as the term for the health care services that play a role in the local community. It can be provided in different settings, such as Urgent care centers which provide same day appointments or services on a walk-in basis.

Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all types of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care based on the reason for the patient's visit.

Common chronic illnesses usually treated in primary care may include, for example: hypertension, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations. In the United States, the 2013 National Health Interview Survey found that skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory tract disease (22.1%, excluding asthma) were the most common reasons for accessing a physician.

In the United States, primary care physicians have begun to deliver primary care outside of the managed care (insurance-billing) system through direct primary care which is a subset of the more familiar concierge medicine. Physicians in this model bill patients directly for services, either on a pre-paid monthly, quarterly, or annual basis, or bill for each service in the office. Examples of direct primary care practices include Foundation Health in Colorado and Qliance in Washington.

In context of global population aging, with increasing numbers of older adults at greater risk of chronic non-communicable diseases, rapidly increasing demand for primary care services is expected in both developed and developing countries.

The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy.

Secondary care

Secondary care includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury, or other health condition. This care is often found in a hospital emergency department.
Secondary care also includes skilled attendance during childbirth, intensive care, and medical imaging services.

The term "secondary care" is sometimes used synonymously with "hospital care". However, many secondary care providers, such as psychiatrists, clinical psychologists, occupational therapists, most dental specialties or physiotherapists, do not necessarily work in hospitals. 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.

In countries which operate under a mixed market health care system, some physicians limit their practice to secondary care by requiring patients to see a primary care provider first. This restriction may be imposed under the terms of the payment agreements in private or group health insurance plans. In other cases, medical specialists may see patients without a referral, and patients may decide whether self-referral is preferred.

In other countries patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician (either a primary care physician or another specialist) is considered necessary, regardless of whether the funding is from private insurance schemes or national health insurance.

Allied health professionals, such as physical therapists, respiratory therapists, occupational therapists, speech therapists, and dietitians, also generally work in secondary care, accessed through either patient self-referral or through physician referral.

Tertiary care

Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.

Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions.

Quaternary care

The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centers.

Home and community care

Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases.

They also include the services of professionals in residential and community settings in support of self care, home care, long-term care, assisted living, treatment for substance use disorders among other types of health and social care services.

Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function. This can include prostheses, orthotics, or wheelchairs.

Many countries, especially in the west, are dealing with aging populations, so one of the priorities of the health care system is to help seniors live full, independent lives in the comfort of their own homes. There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to and from doctor's appointments along with many other activities that are essential for their health and well-being. Although they provide home care for older adults in cooperation, family members and care workers may harbor diverging attitudes and values towards their joint efforts. This state of affairs presents a challenge for the design of ICT (information and communication technology) for home care.

Because statistics show that over 80 million Americans have taken time off of their primary employment to care for a loved one,many countries have begun offering programs such as Consumer Directed Personal Assistant Program to allow family members to take care of their loved ones without giving up their entire income.

With obesity in children rapidly becoming a major concern, health services often set up programs in schools aimed at educating children about nutritional eating habits, making physical education a requirement and teaching young adolescents to have positive self-image.

Ratings

Health care ratings are ratings or evaluations of health care used to evaluate the process of care and health care structures and/or outcomes of health care services. This information is translated into report cards that are generated by quality organizations, nonprofit, consumer groups and media. This evaluation of quality is based on measures of:

.Hospital quality

.Health plan quality

.Physician quality

.Quality for other health professionals

.Patient experience

Private healthcare

Since 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector. The private sector consists of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors.

According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas.

The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas.

In terms of healthcare quality in the private sector, a 2012 study by Sanjay Basu et al., published in PLOS Medicine, indicated that health care providers in the private sector were more likely to spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare. However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure, which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living.

Costs of the private sector are only increasing. One study found that over 35% of poor Indian households incur such expenditure and this reflects the detrimental state in which Indian health care system is at the moment. With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services.
Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the World Bank, about 25% of India's population had some form of health insurance in 2010.

A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India's population was insured. Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices.

In Rajasthan, 40% of practitioners did not have a medical degree and 20% have not completed a secondary education.

On 27 May 2012, the popular actor Aamir Khans program Satyamev Jayate did an episode on "Does Healthcare Need Healing?" which highlighted the high costs and other malpractices adopted by private clinics and hospitals. In response to this, Narayana Health plans to conduct heart operations at a cost of $800 per patient.

Medication

In 1970, the Indian government banned medical patents. India signed the 1995 TRIPS Agreement which allows medical patents, but establishes the compulsory license, where any pharmaceutical company has the right to produce any patented product by paying a fee. This right was used in 2012, when Natco was allow to produce Nexavar, a cancer drug. In 2005, new legislation stipulated that a medicine could not be patented if it did not result in "the enhancement of the known efficacy of that substance".

Indians consumed the most antibiotics per head in the world in 2010. Many antibiotics were on sale in 2018 which had not been approved in India or in the country of origin, although this is prohibited. A survey in 2017 found 3.16% of the medicines sampled were substandard and 0.0245% were fake. Those more commonly prescribed are probably more often faked. Some medications are listed on Schedule H1, which means they should not be sold without a prescription. Pharmacists should keep records of sales with the prescribing doctor and the patient's details.

Patient experience

The patient experience describes an individual's experience of illness/injury and how healthcare treats them. Increasing focus on patient experience is part of a move towards patient-centered care.
It is often operationalised through metrics, a trend related to consumerism and New Managerialism.

Patient experience (PX) is defined as the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.

Patient experience has become a key Quality outcome for healthcare; measuring it is seen to support improvement in healthcare quality, governance, public accountability and, especially in the English NHS, patient choice.Measures of patient experience arose from work in the 1980s and is now there use is now widescale. However, their effectiveness has been questioned and clinicians and managers may disagree about their use.There is a general agreement in the litterature that measuring patient experience can be accomplished using a quantitative, qualitative, or mixed-methods approach.

When patient experience is discussed in terms of experiences with health care services it is similar to patient satisfaction. However, patient experience is often reported in health research as also encompassing people's experiences of illness and injury outside of their experiences with health services, such as those experiences with family and friends, and the influence of illness/injury over their capacity to engage in social activities or previously imagined futures.

For example, researchers might report of the patient experience of living with heart failure or other chronic illnesses.

Patient satisfaction

Patient satisfaction is a measure of the extent to which a patient is content with the health care which they received from their health care provider.

In evaluations of health care quality, patient satisfaction is a performance indicator measured in a self-report study and a specific type of customer satisfaction metric.

Health care quality

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.

Performance indicator

performance indicator or key performance indicator (KPI) is a type of performance measurement.

KPIs evaluate the success of an organization or of a particular activity (such as projects, programs, products and other initiatives) in which it engages.

Often success is simply the repeated, periodic achievement of some levels of operational goal (e.g. zero defects, 10/10 customer satisfaction), and sometimes success is defined in terms of making progress toward strategic goals. Accordingly, choosing the right KPIs relies upon a good understanding of what is important to the organization.What is deemed important often depends on the department measuring the performance – e.g. the KPIs useful to finance will differ from the KPIs assigned to sales.

Since there is a need to understand well what is important, various techniques to assess the present state of the business, and its key activities, are associated with the selection of performance indicators. These assessments often lead to the identification of potential improvements, so performance indicators are routinely associated with 'performance improvement' initiatives. A very common way to choose KPIs is to apply a management framework such as the balanced scorecard.

Points of measurement

Performance focuses on measuring a particular element of an activity. An activity can have four elements: input, output, control, and mechanism. At a minimum, an activity is required to have at least an input and an output. Something goes into the activity as an input; the activity transforms the input by making a change to its state; and the activity produces an output. An activity can also have to enable mechanisms that are typically separated into human and system mechanisms. It can also be constrained in some way by a control. Lastly, its actions can have a temporal construct of time.

1.Input indicates the inputs required of an activity to produce an output.

2.Output captures the outcome or results of an activity or group of activities.

3.Activity indicates the transformation produced by an activity (i.e., some form of work).

4.Mechanism is something that enables an activity to work (a performer), either human or system.

5.Control is an object that controls the activity's production through compliance.

6.Time indicates a temporal element of the activity.

Identifying indicators of organization

Performance indicators differ from business drivers and aims (or goals). A school might consider the failure rate of its students as a key performance indicator which might help the school understand its position in the educational community, whereas a business might consider the percentage of income from returning customers as a potential KPI.

The key stages in identifying KPIs are:
1.Having a pre-defined business process (BP).

2.Having requirements for the BPs.

3.Having a quantitative/qualitative measurement of the results and comparison with set goals.

4.Investigating variances and tweaking processes or resources to achieve short-term goals.

Key performance indicators (KPIs) are ways to periodically assess the performances of organizations, business units, and their division, departments and employees. Accordingly, KPIs are most commonly defined in a way that is understandable, meaningful, and measurable. They are rarely defined in such a way that their fulfillment would be hampered by factors seen as non-controllable by the organizations or individuals responsible. Such KPIs are usually ignored by organizations.

KPIs should follow the SMART criteria. This means the measure has a Specific purpose for the business, it is Measurable to really get a value of the KPI, the defined norms have to be Achievable, the improvement of a KPI has to be Relevant to the success of the organization, and finally it must be Time phased, which means the value or outcomes are shown for a predefined and relevant period.

In order to be evaluated, KPIs are linked to target values, so that the value of the measure can be assessed as meeting expectations or not.

SMART creteria

SMART is a mnemonic/acronym, giving criteria to guide in the setting of objectives, for example in project management, employee-performance management and personal development.

The letters S and M generally mean specific and measurable.

Possibly the most common version has the remaining letters referring to achievable (or attainable), relevant, and time-bound.

However, the term's inventor had a slightly different version and the letters have meant different things to different authors, as described below. Additional letters have been added by some authors.

The first-known use of the term occurs in the November 1981 issue of Management Review by George T. Doran.

The principal advantage of SMART objectives is that they are easier to understand and to know when they have been done. SMART criteria are commonly associated with Peter Drucker's management by objectives concept.

Often the term S.M.A.R.T. Goals and S.M.A.R.T. Objectives will surface. Although the acronym SMART generally stays the same, objectives and goals can differ. Goals are the distinct purpose that is to be anticipated from the assignment or project.

Objectives on the other hand are the determined steps that will direct full completion of the project goals.

Health plan

Health policy can be defined as the "decisions, plans, and actions that are undertaken to achieve specific healthcare goals within a society".

According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people.

There are many categories of health policies, including global health policy, public health policy, mental health policy, health care services policy, insurance policy, personal healthcare policy, pharmaceutical policy, and policies related to public health such as vaccination policy, tobacco control policy or breastfeeding promotion policy. They may cover topics of financing and delivery of healthcare, access to care, quality of care, and health equity.

Insurance policy

The insurance policy is a contract (generally a standard form contract) between the insurer and the insured, known as the policyholder, which determines the claims which the insurer is legally required to pay. In exchange for an initial payment, known as the premium, the insurer promises to pay for loss caused by perils covered under the policy language.

Insurance contracts are designed to meet specific needs and thus have many features not found in many other types of contracts. Since insurance policies are standard forms, they feature boilerplate language which is similar across a wide variety of different types of insurance policies.

The insurance policy is generally an integrated contract, meaning that it includes all forms associated with the agreement between the insured and insurer.

In some cases, however, supplementary writings such as letters sent after the final agreement can make the insurance policy a non-integrated contract One insurance textbook states that generally "courts consider all prior negotiations or agreements ... every contractual term in the policy at the time of delivery, as well as those written afterward as policy riders and endorsements ... with both parties' consent, are part of the written policy". The textbook also states that the policy must refer to all papers which are part of the policy.Oral agreements are subject to the parol evidence rule, and may not be considered part of the policy if the contract appears to be whole. Advertising materials and circulars are typically not part of a policy.
Oral contracts pending the issuance of a written policy can occur.

Parts of an insurance contract

Declarations - identifies who is an insured, the insured's address, the insuring company, what risks or property are covered, the policy limits (amount of insurance), any applicable deductibles, the policy period and premium amount.

These are usually provided on a form that is filled out by the insurer based on the insured's application and attached on top of or inserted within the first few pages of the policy.

Definitions - Defines important terms used in the rest of the policy.

Insuring agreement - Describes the covered perils, or risks assumed, or nature of coverage. This is where the insurance company makes one or more express promises to indemnify the insured.

Exclusions - Takes coverage away from the insuring agreement by describing property, perils, hazards or losses arising from specific causes which are not covered by the policy.

Conditions - These are specific provisions, rules of conduct, duties, and obligations that the insured must comply with in order for coverage to incept or must remain in compliance with in order to keep coverage in effect. If policy conditions are not met, the insurer can deny the claim.

Policy form - The definitions, insuring agreement, exclusions, and conditions are typically combined into a single integrated document called a policy form, coverage form, or coverage part. When multiple coverage forms are packaged into a single policy, the declarations will state as much, and then there may be additional declarations specific to each coverage form. Traditionally, policy forms have been so rigidly standardized that they have no blank spaces to be filled in. Instead, they always expressly refer to terms or amounts stated in the declarations. If the policy needs to be customized beyond what is possible with the declarations, then the underwriter attaches endorsements or riders.

Endorsements - Additional forms attached to the policy that modify it in some way, either unconditionally or upon the existence of some condition.

Endorsements can make policies difficult to read for nonlawyers; they may revise, expand, or delete clauses located many pages earlier in one or more coverage forms, or even modify each other. Because it is very risky to allow nonlawyer underwriters to directly rewrite policy forms with word processors, insurers usually direct underwriters to modify them by attaching endorsements preapproved by counsel for various common modifications.

Riders - A rider is used to convey the terms of a policy amendment and the amendment thereby becomes part of the policy. Riders are dated and numbered so that both insurer and policyholder can determine provisions and the benefit level. Common riders to group medical plans involve name changes, change to eligible classes of employees, change in level of benefits, or the addition of a managed care arrangement such as a Health Maintenance Organization or Preferred Provider Organization (PPO).

Jackets - The term has several distinct and confusing meanings. In general, it refers to some set of standard boilerplate provisions which accompanies all policies at the time of delivery. Some insurers refer to a package of standard documents shared across an entire family of policies as a "jacket." Some insurers extend this to include policy forms, so that the only parts of the policy not part of the jacket are the declarations, endorsements, and riders. Other insurers use the term "jacket" in a manner closer to its ordinary meaning: a binder, envelope, or presentation folder with pockets in which the policy may be delivered, or a cover sheet to which the policy forms are stapled or which is stapled on top of the policy. The standard boilerplate provisions are then printed on the jacket itself.

Access to healthcare

There are 14 million doctors in India.

Yet, India has failed to reach its Millennium Development Goals related to health.The definition of 'access is the ability to receive services of a certain quality at a specific cost and convenience.

The healthcare system of India is lacking in three factors related to access to healthcare: provision, utilization, and attainment. Provision, or the supply of healthcare facilities, can lead to utilization, and finally attainment of good health. However, there currently exists a huge gap between these factors, leading to a collapsed system with insufficient access to healthcare.Differential distributions of services, power, and resources have resulted in inequalities in healthcare access.

Access and entry into hospitals depends on gender, socioeconomic status, education, wealth, and location of residence (urban versus rural).

Furthermore, inequalities in financing healthcare and distance from healthcare facilities are barriers to access. Additionally, there is a lack of sufficient infrastructure in areas with high concentrations of poor individuals.Large numbers of tribes and ex-untouchables that live in isolated and dispersed areas often have low numbers of professionals.Finally, health services may have long wait times or consider ailments as not serious enough to treat.Those with the greatest need often do not have access to healthcare.

Electronic health records

The Government of India, while unveiling the National Health Portal, has come out with guidelines for Electronic health record standards in India. The document recommends a set of standards to be followed by different healthcare service providers in India, so that medical data becomes portable and easily transferable.

India is considering to set up a National eHealth Authority (NeHA) for standardisation, storage and exchange of electronic health records of patients as part of the government's Digital India programme. The authority, to be set up by an Act of Parliament will work on the integration of multiple health IT systems in a way that ensures security, confidentiality and privacy of patient data. A centralised electronic health record repository of all citizens which is the ultimate goal of the authority will ensure that the health history and status of all patients would always be available to all health institutions. Union Health Ministry has circulated a concept note for the setting up of NeHa, inviting comments from stakeholders.

Rural areas

Rural areas in India have a shortage of medical professionals.

74% of doctors are in urban areas that serve the other 28% of the population. This is a major issue for rural access to healthcare. The lack of human resources causes citizens to resort to fraudulent or ignorant providers. Doctors tend not to work in rural areas due to insufficient housing, healthcare, education for children, drinking water, electricity, roads and transportation. Additionally, there exists a shortage of infrastructure for health services in rural areas.

In fact, urban public hospitals have twice as many beds as rural hospitals, which are lacking in supplies. Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities. Full immunization coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India.
Inequalities in healthcare can result from factors such as socioeconomic status and caste, with caste serving as a social determinant of healthcare in India.

Rural south India

A 2007 study by Vilas Kovai et al., published in the Indian Journal of Ophthalmology analyzed barriers that prevent people from seeking eye care in rural Andhra Pradesh, India. The results displayed that in cases where people had awareness of eyesight issues over the past five years but did not seek treatment, 52% of the respondents had personal reasons (some due to own beliefs about the minimal extent of issues with their vision), 37% economic hardship, and 21% social factors (such as other familial commitments or lacking an accompaniment to the healthcare facility).

The role of technology, specifically mobile phones in health care has also been explored in recent research as India has the second largest wireless communication base in the world, thus providing a potential window for mobile phones to serve in delivering health care.Specifically, in one 2014 study conducted by Sherwin DeSouza et al. in a rural village near Karnataka, India, it was found that participants in community who owned a mobile phone (87%) displayed a high interest rate (99%) in receiving healthcare information through this mode, with a greater preference for voice calls versus SMS (text) messages for the healthcare communication medium. Some specific examples of healthcare information that could be provided includes reminders about vaccinations and medications and general health awareness information.

Rural north India

The distribution of healthcare providers varies for rural versus urban areas in North India.

A 2007 study by Ayesha De Costa and Vinod Diwan, published in Health Policy, conducted in Madhya Pradesh, India examined the distribution of different types of healthcare providers across urban and rural Madhya Pradesh in terms of the differences in access to healthcare through number of providers present.
The results indicated that in rural Madhya Pradesh, there was one physician per 7870 people, while there was one physician per 834 people in the urban areas of the region.In terms of other healthcare providers, the study found that of the qualified paramedical staff present in Madhya Pradesh, 71% performed work in the rural areas of the region. In addition, 90% of traditional birth attendants and unqualified healthcare providers in Madhya Pradesh worked in the rural communities.

Studies have also investigated determinants of healthcare-seeking behavior (including socioeconomic status, education level, and gender), and how these contribute to overall access to healthcare accordingly. A 2016 study by Wameq Raza et al., published in BMC Health Services Research, specifically surveyed healthcare-seeking behaviors among people in rural Bihar and Uttar Pradesh, India. The findings of the study displayed some variation according to acute illnesses versus chronic illnesses. In general, it was found that as socioeconomic status increased, the probability of seeking healthcare increased.Educational level did not correlate to probability of healthcare-seeking behavior for acute illnesses, however, there was a positive correlation between educational level and chronic illnesses.This 2016 study also considered the social aspect of gender as a determinant for health-seeking behavior, finding that male children and adult men were more likely to receive treatment for acute ailments compared to their female counterparts in the areas of rural Bihar and Uttar Pradesh represented in the study.

These inequalities in healthcare based on gender access contribute towards the differing mortality rates for boys versus girls, with the mortality rates greater for girls compared to boys, even before the age of five.

Other previous studies have also delved into the influence of gender in terms of access to healthcare in rural areas, finding gender inequalities in access to healthcare.

A 2002 study conducted by Aparna Pandey et al., published in the Journal of Health, Population, and Nutrition, analyzed care-seeking behaviors by families for girls versus boys, given similar sociodemographic characteristics in West Bengal, India.

In general, the results exhibited clear gender differences such that boys received treatment from a healthcare facility if needed in 33% of the cases, while girls received treatment in 22% of the instances requiring care. Furthermore, surveys indicated that the greatest gender inequality in access to healthcare in India occurred in the provinces of Haryana, and Punjab.

Urban Areas

The problem of healthcare access arises not only in huge cities but in rapidly growing small urban areas.Here, there are fewer available options for healthcare services and there are less organized governmental bodies. Thus, there is often a lack of accountability and cooperation in healthcare departments in urban areas.

It is difficult to pinpoint an establishment responsible for providing urban health services, compared to in rural areas where the responsibility lies with the district administration.

Additionally, health inequalities arise in urban areas due to difficulties in residence, socioeconomic status, and discrimination against unlisted slums.

To survive in this environment, urban people use non-governmental, private services which are plentiful. However, these are often understaffed, require three times the payment as a public center, and commonly have bad practice methods. To counter this, there have been efforts to join the public and private sectors in urban areas.

An example of this is the Public-Private Partnerships initiative. However, studies show that in contrast to rural areas, qualified physicians tend to reside in urban areas. This can be explained by both urbanization and specialization. Private doctors tend to be specialized in a specific field so they reside in urban areas where there is a higher market and financial ability for those services.

Financing

Despite being one of the most populous countries, India has the most private healthcare in the world. Out-of-pocket private payments make up 75% of the total expenditure on healthcare.Only one fifth of healthcare is financed publicly.This is in stark contrast to most other countries of the world. According to the World Health Organization in 2007, India ranked 184 out of 191 countries in the amount of public expenditure spent on healthcare out of total GDP.

In fact, public spending stagnated from 0.9% to 1.2% of total GDP in 1990 to 2010.

Medical and non-medical out-of-pocket private payments can affect access to healthcare.

Poorer populations are more affected by this than the wealthy. The poor pay a disproportionately higher percent of their income towards out-of-pocket expenses than the rich.

The Round National Sample Survey of 1955 through 1956 showed that 40% of all people sell or borrow assets to pay for hospitalization. Half of the bottom two quintiles go into debt or sell their assets, but only a third of the top quintiles do.

In fact, about half the households that drop into the lower classes do so because of health expenditures.This data shows that financial ability plays a role in determining healthcare access.

In terms of non-medical costs, distance can also prevents access to healthcare. Costs of transportation prevent people from going to health centers. According to scholars, outreach programs are necessary to reach marginalized and isolated groups.

In terms of medical costs, out-of-pocket hospitalization fees prevent access to healthcare. 40% of people that are hospitalized are pushed either into lifelong debt or below the poverty line. Furthermore, over 23% of patients don't have enough money to afford treatment and 63% lack regular access to necessary medications. Healthcare and treatment costs have inflated 10–12% a year and with more advancements in medicine, costs of treatment will continue to rise.

Finally, the price of medications rise as they are not controlled.

There is a major gap between outreach, finance and access in India. Without outreach, services cannot be spread to distant locations.

Without financial ability, those in distant locations cannot afford to access healthcare.According to scholars, both of these issues are tied together and are pitfalls of the current healthcare system.

Initiatives to improve access

Government-led
(The Twelfth Plan )

The government of India has a Twelfth Plan to expand the National Rural Health Mission to the entire country, known as the National Health Mission.Community based health insurance can assist in providing services to areas with disadvantaged populations.

Additionally, it can help to emphasize the responsibility of the local government in making resources available. Furthermore, according to the Indian Journal of Community Medicine (IJOCM) the government should reform health insurance as well as its reach in India. The journal states that universal healthcare should slowly yet steadily be expanded to the entire population. Healthcare should be mandatory and no money should be exchanged at appointments. Finally, both private and public sectors should be involved to ensure all marginalized areas are reached. According to the IJOCM, this will increase access for the poor.

Twelfth Five Year Plan (India).

National Rural Health Mission

To counteract the issue of a lack of professionals in rural areas, the government of India wants to create a 'cadre' of rural doctors through governmental organizations.

The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The NRHM has outreach strategies for disadvantaged societies in isolated areas.

The goal of the NRHM is to provide effective healthcare to rural people with a focus on 18 states with poor public health indicators and/or weak infrastructure.

NRHM has 18,000 ambulances and a workforce of 900,000 community health volunteers and 178,000 paid staff. The mission proposes creating a course for medical students that is centered around rural healthcare. Furthermore, NRHM wants to create a compulsory rural service for younger doctors in the hopes that they will remain in rural areas. However, the NRHM has failings. For example, even with the mission, most construction of health related infrastructure occurs in urban cities. Many scholars call for a new approach that is local and specialized to each state's rural areas.Other regional programs such as the Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh, India have also been implemented by state governments to assist rural populations in healthcare accessibility, but the success of these programs (without other supplemental interventions at the health system level) has been limited.

National Urban Health Mission

The National Urban Health Mission as a sub-mission of National Health Mission was approved by the cabinet on 1 May 2013.

The National Urban Health Mission (NUHM) works in 779 cities and towns with populations of 50,000 each. As urban health professionals are often specialized, current urban healthcare consists of secondary and tertiary, but not primary care.

Thus, the mission focusses on expanding primary health services to the urban poor.

The initiative recognizes that urban healthcare is lacking due to overpopulation, exclusion of populations, lack of information on health and economic ability, and unorganized health services

Thus, NUHM has appointed three tiers that need improvement: Community level (including outreach programs), Urban Health Center level (including infrastructure and improving existing health systems), and Secondary/Tertiary level (Public-Private Partnerships).

Furthermore, the initiative aims to have one Urban Public Health Center for each population of 50,000 and aims to fix current facilities and create new ones. It plans for small municipal governments to take responsibility for planning healthcare facilities that are prioritized towards the urban poor, including unregistered slums and other groups.

Additionally, NUHM aims to improve sanitation and drinking water, improve community outreach programs to further access, reduce out-of-pocket expenses for treatment, and initiate monthly health and nutrition days to improve community health.

Pradhan Mantri Jan Arogya Yojana(PM-JAY)

Pradhan Mantri Jan Arogya Yojana (PM-JE) is a leading initiative of Prime Minister Modi to ensure health coverage for the poor and weaker population in India. This initiative is part of the government's view to ensure that its citizens – particularly poor and weaker groups, have access to healthcare and good quality hospital services without facing financial difficulty.

PM-JAY Provides insurance cover up to Rs 5 lakh per annum to the 100 million families in India for secondary and tertiary hospitalization. For transparency, the government made an online portal (Mera PmJay) to check eligibility for PMJAY. Health care service includes follow-up care, daycare surgeries, pre and post hospitalization, hospitalization expenses, expense benefits and newborn child/children services. The comprehensive list of services is available on the website.

Public-private partnership

One initiative adapted by governments of many states in India to improve access to healthcare entails a combination of public and private sectors. The Public-Private Partnership Initiative (PPP) was created in the hopes of reaching the health-related Millennium Development Goals.In terms of prominence, nearly every new state health initiative includes policies that allow for the involvement of private entities or non-governmental organizations.

Major programs

Fair Price Shops aim to reduce the costs of medicines, drugs, implants, prosthetics, and orthopedic devices. Currently, there is no competition between pharmacies and medical service stores for the sale of drugs. Thus, the price of drugs is uncontrolled.

The Fair Price program creates a bidding system for cheaper prices of medications between drugstores and allows the store with the greatest discount to sell the drug. The program has a minimal cost for the government as fair price shops take the place of drugstores at government hospitals, thus eliminating the need to create new infrastructure for fair price shops.Furthermore, the drugs are unbranded and must be prescribed by their generic name. As there is less advertising required for generic brands, fair price shops require minimal payment from the private sector. Fair Price Shops were introduced in the West Bengal in 2012. By the end of the year, there were 93 stores benefiting 85 lakh people. From December 2012 to November 2014, these shops had saved 250 crore citizens.As doctors prescribe 60% generic drugs, the cost of treatment has been reduced by this program. This is a solution to affordability for health access in West Bengal.

The largest segment of the PPP initiative is the tax-financed program, Rashtriya Swasthya Bima Yojana (RSBY).The scheme is financed 75% by the central government and 25% by the state government.This program aims to reduce medical out-of-pocket costs for hospital treatment and visits by reimbursing those that live below the poverty line. RSBY covers maximum 30,000 rupees in hospital expenses, including pre-existing conditions for up to five members in a family.

In 2015, it reached 37 million households consisting of 129 million people below the poverty line. However, a family has to pay 30 rupees to register in the program.[46] Once deemed eligible, family members receive a yellow card.However, studies show that in Maharashtra, those with a lower socioeconomic status tend to not use the service, even if they are eligible.In the state of Uttar Pradesh, geography and council affect participation in the program. Those in the outskirts of villages tend to use the service less than those who live in the center of villages.

Additionally, studies show household non-medical expenses as increasing due to this program; the probability of incurring out-of-pocket expenses has increased by 23%.

However, RSBY has stopped many from falling into poverty as a result of healthcare.Furthermore, it has improved opportunities for family members to enter the workforce as they can utilize their income for other needs besides healthcare.

RSBY has been applied in 25 states of India.

Finally, the National Rural Telemedicine Network connects many healthcare institutions together so doctors and physicians can provide their input into diagnosis and consultations.

This reduces the non-medical cost of transportation as patients do not have to travel far to get specific doctor's or specialty's opinions. However, problems arise in terms of the level of care provided by different networks. While some level of care is provided, telemedical initiatives are unable to provide drugs and diagnostic care, a necessity in rural areas.

Effectiveness

The effectiveness of public-private partnerships in healthcare is hotly disputed. Critics of PPP are concerned of its presentation as a cure-all solution, by which the health infrastructure can be improved.

Proponents of PPP claim that these partnerships take advantage of existing infrastructure in order to provide care for the underprivileged.

The results of the PPP in the states of Maharashtra and West Bengal show that all three of these programs are effective when used in combination with federal health services. They assist in filling the gap between outreach and affordability in India.However, even with these programs, high out-of-pocket payments for non-medical expenses are still deterring people from healthcare access.

Thus, scholars state that these programs need to be expanded across India.

A case study of tuberculosis control in rural areas, in which PPP was utilized showed limited effectiveness; while the program was moderately effective, a lack of accountability forced the program to shut down.

Similar issues in accountability were seen by the parties involved within other PPP schemes. Facilitators and private practitioners, when asked about PPP, identified lack of state support, in the form of adequate funding, and a lack of coordination, as primary reasons why PPP ventures are unsuccessful.

In the most successful PPP ventures, the World Health Organization found that the most prominent factor, aside from financial support, was ownership of the project by state and local governments.

It was found that programs sponsored by the state governments were more effective in achieving health goals than programs set by national governments.

India's has setup a National Telemedicine Taskforce by the Health Ministry of India, in 2005, paved way for the success of various projects like the ICMR-AROGYASREE, NeHA and VRCs. Telemedicine also helps family physicians by giving them easy access to speciality doctors and helping them in close monitoring of patients. Different types of telemedicine services like store and forward, real-time and remote or self-monitoring provides various educational, healthcare delivery and management, disease screening and disaster management services all over the globe. Even though telemedicine cannot be a solution to all the problems, it can surely help decrease the burden of the healthcare system to a large extent.[50] India has grown to see multiple Telemedicine platforms like the ApolloAsk, Practo, TeleDoc, DocInsta and much over the recent years.

Quality of healthcare

Non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas are becoming big challenges. Rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector.But there are incidents where doctors were attacked and even killed in rural India.

In 2015 the British Medical Journal published a report by Dr Gadre, from Kolkata, exposed the extent of malpractice in the Indian healthcare system. He interviewed 78 doctors and found that kickbacks for referrals, irrational drug prescribing and unnecessary interventions were commonplace.

According to a study conducted by Martin Patrick, CPPR chief economist released in 2017 has projected people depend more on private sector for healthcare and the amount spent by a household to avail of private services is almost 24 times more than what is spent for public healthcare services.

South India

In many rural communities throughout India, healthcare is provided by what is known as informal providers, who may or may not have proper medical accreditation to diagnose and treat patients, generally offering consults for common ailments. Specifically, in Guntur, Andhra Pradesh, India, these informal healthcare providers generally practice in the form of services in the homes of patients and prescribing allopathic drugs.

A 2014 study by Meenakshi Gautham et al., published in the journal Health Policy and Planning, found that in Guntur, about 71% of patients received injections from informal healthcare providers as a part of illness management strategies.

The study also examined the educational background of the informal healthcare providers and found that of those surveyed, 43% had completed 11 or more years of schooling, while 10% had graduated from college.

In general, the perceived quality of healthcare also has implications on patient adherence to treatment.
A 2015 study conducted by Nandakumar Mekoth and Vidya Dalvi, published in Hospital Topics examined different aspects that contribute to a patient's perception of quality of healthcare in Karnataka, India, and how these factors influenced adherence to treatment. The study incorporated aspects related to quality of healthcare including interactive quality of physicians, base-level expectation about primary health care facilities in the area, and non-medical physical facilities (including drinking water and restroom facilities).
In terms of adherence to treatment, two sub-factors were investigated, persistence of treatment and treatment-supporting adherence (changes in health behaviors that supplement the overall treatment plan). The findings indicated that the different quality of healthcare factors surveyed all had a direct influence on both sub-factors of adherence to treatment.

Furthermore, the base-level expectation component in quality of healthcare perception, presented the most significant influence on overall adherence to treatment, with the interactive quality of physicians having the least influence on adherence to treatment, of three aspects investigated in this study.

North India

In a particular district of Uttarakhand, India known as Tehri, the educational background of informal healthcare providers indicated that 94% had completed 11 or more years of schooling, while 43% had graduated from college.

In terms of the mode of care delivered, 99% of the health services provided in Tehri were through the clinic, whereas in Guntur, Andhra Pradesh, 25% of the health care services are delivered through the clinic, while 40% of the care provided is mobile (meaning that healthcare providers move from location to location to see patients), and 35% is a combination of clinic and mobile service.

In general throughout India, the private healthcare sector does not have a standard of care that is present across all facilities, leading to many variations in the quality of care provided.

In particular, a 2011 study by Padma Bhate-Deosthali et al., published in Reproductive Health Matters, examined the quality of healthcare particularly in the area of maternal services through different regions in Maharashtra, India. The findings indicated that out of 146 maternity hospitals surveyed, 137 of these did not have a qualified midwife, which is crucial for maternity homes as proper care cannot be delivered without midwives in some cases.

In addition, the 2007 study by Ayesha De Costa and Vinod Diwan analyzed the distribution of healthcare providers and systems in Madhya Pradesh, India.

The results indicated that among solo practitioners in the private sector for that region, 62% practiced allopathic (Western) medicine, while 38% practiced Indian systems of medicine and traditional systems (including, but not limited to ayurveda, sidhi, unani, and homeopathy).

In certain areas, there are also gaps in the knowledge of healthcare providers about certain ailments that further contribute towards quality of healthcare delivered when treatments are not fully supported with thorough knowledge about the ailment. A 2015 study by Manoj Mohanan et al., published in JAMA Pediatrics, investigate the knowledge base of a sample of practitioners (80% without formal medical degrees) in Bihar, India, specifically in the context of childhood diarrhea and pneumonia treatment. The findings indicated that in general, a significant number of practitioners missed asking key diagnostic questions regarding symptoms associated with diarrhea and pneumonia, leading to misjudgments and lack of complete information when prescribing treatments.

Among the sample of practitioners studied in rural Bihar, 4% prescribed the correct treatment for the hypothetical diarrhea cases in the study, and 9% gave the correct treatment plan for the hypothetical pneumonia cases presented.Recent studies have examined the role of educational or training programs for healthcare providers in rural areas of North India as a method to promote higher quality of healthcare, though conclusive results have not yet been attained.

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