India’s dispiriting record

World Health Day

By Moin Qazi

India’s economy is soaring and is now the world’s envy, but its healthcare system remains an Achilles’ heel. As World Heath Day (7th April) is observed today, for millions of people in India, the high cost of treating illnesses continues to undermine economic progress. This is largely on account of the dilapidated health care system: a major symptom of the dire lack of funding. The nation ranks poorly in international rankings on most health indices.
With an investment of 1.3% of GDP in health services, which has remained at the same level for a decade (global average is 5.99%), India ranked 187th of 194 countries according to the World Health Organisation (WHO) while accounting for a full 20% of the global healthcare burden. Comparable rates are 1.5% in Sri Lanka, 2.7% in China, and 3% in Thailand.
A recent heartening development is the Government finally waking up to the seriousness of the health crisis. In a major stride towards universal health coverage it announced the National Health Protection Scheme (NHPS), dubbed Modicare, which will insure 10 crore families for Rs 5 lakh each every year making it the largest public health scheme. If the government lives up to its high-minded pronouncements, the scheme could be life changing and transformative for a country, where affordable and safe healthcare is elusive to millions of families.
NHPS promises to bring health care system closer to the homes through 1.5 lakh health and wellness centres, as part of the ‘Ayushman Bharat’ to address health holistically, in the primary, secondary and tertiary care system. However, this is not a new concept; only a fancy name has been used for our decade’s old primary health care centres, which are planned to be upgraded to meet the new goal.
The State’s past records in primary healthcare has been quite dispiriting. During the past 15 years India’s population grew 15% but the number of village health centers, front line of public health care system, diminished by 8% because they have fallen into disuse on account of lack of staff.
Illnesses are a severe risk which takes a huge bite out of the earnings of the poor. Health financing poses an acute challenge. Many people have to take steep loans or sell their assets in order to pay. For the poor, losing wages while navigating the byzantine processes in public hospitals can be crippling. Healthcare expenses are a major cause of impoverishment of working families in India. Private healthcare’s catastrophic costs can shave off most of the hard-earned savings of patients and their families. Hence, they become a primary route to bankruptcy.
The Ministry of Health has found that a quarter of all people hospitalised were driven to penury by their hospital costs, not including the cost of missed work. All these have damaging spillover consequences: money pulled from household savings for medical care means less to spend on food, education, housing and long-term plans. According to David Dror, who has closely observed health insurance in India, “A health event is a bigger risk to farmers than an unsuccessful crop. Once they sell their land or livestock, they become indentured laborers. That takes a generation to fix.”
The WHO has stated that 50-65% of Indians do not have regular access even to essential medicines. This is ironic for a country which is regarded as the “world’s pharmacy”. India is the largest producer of generic medicines. The Government must procure generic medicines in bulk and distribute them free of cost at public health centers to reduce financial and mental burden on the less privileged.
Though the healthcare facilities have grown significantly in terms of numbers and expertise, this has largely been in the private sector. Government hospitals appear to be crumbling as they remain woefully under-resourced, understaffed and poorly managed on account of which they are not able to deliver quality care. This has led to a rapid mushrooming of unregulated for-profit private providers, which today account for 93% of all hospitals, up from 8% in 1947, and they account for 64% of all beds and 80-85% of all doctors.
However, mass access continues to remain a challenge. For the private sector, affordability in tier three cities and rural areas is a critical limiting factor for further expansion. A major problem is the vast disparity in health care access and delivery between the rich and poor and the urban and rural areas.
The 71st National Sample Survey (NSS) undertaken during January-June 2014 revealed that of the total hospitalisation cases in rural areas, 58% were in private clinics and 42% were in public hospitals. The corresponding figures for urban areas were 68% in private and 32% in public. The other indices of India’s healthcare are also highly depressing: 63 million people are pushed into poverty every year on account of health-related expenses!
Out-of-Pocket (OOP) expenditure on healthcare in India — personal spending — contributes approximately 86% of private expenditure and 60% of overall healthcare expenditure and is much more than the rates in countries like Thailand (25%) and China (44%). Hospital bed density is 0.9 per 1,000 persons, in comparison to WHO stipulated minimum guidelines of 3.5 per 1,000 and it has only 0.7 doctors per 1,000 as against minimum doctor-to-patient ratio of 1:1,000.
According to the international consultancy KPMG, the number of healthcare personnel and infrastructure is highly disproportionate for India’s burgeoning population and voluminous disease burden. The country shares about 20% of the burden of global diseases. However, in terms of global infrastructure share, India has only 6% beds and 8% doctors. In terms of public healthcare coverage, the statistics are horrific. There is one Government doctor for every 10,189 people, one hospital bed for every 2,046 people, and one government-run hospital for every 90,343 people. These are certainly mind-numbing figures.
The poor prefer health insurance to life insurance, as they say, “we die once but go to the doctor many times each year.” By hedging life’s uncertainties, they are in a position to protect the wealth they accumulate, generate more income, and can even get a fair chance to rescue themselves and their families out of the mire of poverty.
Non-communicable diseases (NCDs)-or chronic diseases-are the new challenge for health sector. These are increasing at an alarming rate in rural India where government-run healthcare system largely focuses on maternal and child health and infection. These are diseases of long duration and generally slow progression. The four main types of NCDs are cardiovascular diseases (like heart attacks and stroke), cancer, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.
Unlike the largely short-term effects of communicable diseases, the dual health and economic impacts of non-communicable diseases on individuals, families and households are both devastating and long-lasting. It is estimated that India is likely to lose US $4.58 trillion before 2030 due to NCDs.
The Government needs to supplement curative services with preventive measures by strengthening ancillary civic services like insect management, water purification systems sewage systems and treatment of waste. Poor people are dying from diarrhea, pneumonia, under nutrition, malaria tuberculosis and this is the result of poor hygiene and sanitation.
Finally, India must revitalise the public health system to ensure access, outcome, quality and affordability. The focus must be on finding solutions which are affordable, scalable and yet high-quality. For a country which has a rich political history of broken promises, nothing sort of a sustained political will can help us to the goalpost. —INFA