Cost of delivering primary healthcare services through public sector in India

Background & objectives: Public health spending on primary healthcare has increased by four times (in real terms) over the last decade and continues to constitute more than half of the total public health expenditure. The present study estimated the cost of providing healthcare services at sub centre (SC) and primary health centre (PHC) level in four selected States of India. Methods: A total of 51 SCs and 33 PHCs were selected across the four States (Himachal Pradesh, Odisha, Kerala and Tamil Nadu) of India. The economic cost of delivering health services at these facilities was assessed using bottom-up costing methodology during the reference year of 2014-2015. The cost of capital items was annualized and allocation of shared resources was based on appropriate apportioning statistics. Results: The mean annual cost of providing health services at SC and PHC was ? 0.69 million (US$ 11,392) and ? 5.1 million (US$ 83,837), respectively. Nearly 3/4th and 2/3rd of this cost at the level of SC (74%) and PHC (63%) were spent on salaries. In terms of unit cost, the costs per antenatal care and postnatal care visit were ? 221 (173-276) and ? 333 (244-461), respectively, at SCs. Similarly, the costs of per patient outpatient consultation and per bed day hospitalization at PHC level were ? 121 (91-155) and ? 1168 (955-1468), respectively. Interpretation & conclusions: The cost estimates from the present study can be used in economic evaluations, assessing technical efficiency and also for providing valuable information during scale-up of health facilities.

A cross-sectional survey of the models in Bihar and Tamil Nadu, India for pooled procurement of medicines.

Background: In India, access to medicine in the public sector is significantly affected by the efficiency of the drug procurement system and allied processes and policies. This study was conducted in two socioeconomically different states: Bihar and Tamil Nadu. Both have a pooled procurement system for drugs but follow different models. In Bihar, the volumes of medicines required are pooled at the state level and rate contracted (an open tender process invites bidders to quote for the lowest rate for the list of medicines), while actual invoicing and payment are done at district level. In Tamil Nadu, medicine quantities are also pooled at state level but payments are also processed at state level upon receipt of laboratory quality-assurance reports on the medicines. Methods: In this cross-sectional survey, a range of financial and non-financial data related to procurement and distribution of medicine, such as budget documents, annual reports, tender documents, details of orders issued, passbook details and policy and guidelines for procurement were analysed. In addition, a so-called ABC analysis of the procurement data was done to to identify high-value medicines. Results: It was observed that Tamil Nadu had suppliers for 100% of the drugs on their procurement list at the end of the procurement processes in 2006, 2007 and 2008, whereas Bihar’s procurement agency was only able to get suppliers for 56%, 59% and 38% of drugs during the same period. Further, it was observed that Bihar’s system was fuelling irrational procurement; for example, fluconazole (antifungal) alone was consuming 23.4% of the state’s drug budget and was being procured by around 34% of the districts during 2008–2009. Also, the ratios of procurement prices for Bihar compared with Tamil Nadu were in the range of 1.01 to 22.50. For 50% of the analysed drugs, the price ratio was more than 2, that is, Bihar’s procurement system was procuring the same medicines at more than twice the prices paid by Tamil Nadu. Conclusion: Centralized, automated pooled procurement models like that of Tamil Nadu are key to achieving the best procurement prices and highest possible access to medicines.

Universal access to medicines: evidence from Rajasthan, India

India has outlined its commitment to achieving universal health coverage and several states in India are rolling out strategies to support this aim. In 2011, Rajasthan implemented an ambitious universal access to medicines programme based on a centralized procurement and decentralized distribution model. In terms of the three dimensions of universal health coverage, the scheme has made significant positive strides within a short period of implementation. The key objectives of this paper are to assess the likely implications of providing universal access to essential medicines in Rajasthan, which has a population of 70 million. Primary field-level data were obtained from 112 public health-care facilities using multistage random sampling. National Sample Survey Organization data and health system data were also analysed. The per capita health expenditure during the pre-reform period was estimated to be `5.7 and is now close to `50. Availability of essential medicines was encouraging and utilization of public facilities had increased. With additional per capita annual investment of `43, the scheme has brought about several improvements in the delivery of essential services and increased utilization of public facilities in the state and, as a result, enhanced efficiency of the system. Although there was an attempt to convert the scheme into a targeted one with the change in government, strong resistance from the civil society resulted in such efforts being defeated and the universality of the scheme has been retained.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.