India’s health care sector is in a comatose state. I must have heard this a zillion times --- and now even the word --- comatose --- sounds terminal to me. I am sure you felt the same when you read the first line. I don’t blame you: Truth is always bitter, they say. Sometimes it could be boring too.
The health sector’s pitiable state hit home hard recently when my woman-Friday fell sick. “I have typhoid,” she said weakly one morning and went home. I wasn’t expecting to see her for three weeks but she resurfaced after four days.
Surprised, I sent her blood test report to a doctor friend. “There was no indication of typhoid; it was a bout of viral,” she wrote back. A local doctor asked her to do the blood test and also gave injections and the bill came to Rs 1,000. “The government hospital is forever crowded, so I went to the private clinic,” my house help explained when I told her about the wrong (deliberate?) diagnosis. I wondered, is there is a cosy nexus there between the doctor and the lab.
Public health care in India is in a shambles. In the last one month, I have read at least four stories that show its skeletal existence. In Orissa, a man was found carrying his wife’s body because there were no mortuary vans available; in Madhya Pradesh, a bus conductor offloaded man on a highway after his ailing wife died on the bus; in Uttar Pradesh (Kanpur), a 12-year-old boy died on his father’s shoulder because he was denied timely treatment; and in Bihar (Muzaffarpur), a man was made to crawl from one place to another to seek medical aid, with the hospital administration and the government health facility remaining insensitive to his plight.
And, why talk about rural health care? Even well equipped Delhi hospitals are finding it difficult to tackle the outbreak of dengue and chikungunya. Instead of tackling the issue head on, the Delhi government is fighting the Lieutenant Governor over whose responsibility it is to tackle it. Despite 11 deaths due to chikungunya-related complications, you have the Union health minister JP Nadda and Delhi health minister saying that the disease does not cause deaths. As health ministers, the least they should have been aware of is that chikungunya outbreaks have caused deaths across the world, largely among those whose health has already been compromised. According to the World Health Organisation data, in 2005–2006, Réunion Island in the Indian Ocean reported around 2.6 lakh chikungunya cases and 254 deaths.
A report in IndiaSpend, a data journalism initiative, says that India is short of nearly 500,000 doctors, based on the World Health Organization norm of 1:1,000 population. To know the reasons for such a dismal scenario --- worse than even Vietnam, Algeria and Pakistan ---- read a parliamentary standing panel report on health and family welfare on the functioning of the Medical Council of India. “The major source of professional health care for rural and also urban poor households is through the public sector, which is inefficient in infrastructure, human resources and equipment and drugs (especially at the primary level),” the report said.
The first point at which a doctor is available in rural health care system is at the primary health care centre. There are 25,308 PHCs (March 31, 2015) for a rural population of 83.3 crore plus. “This is just a drop in the ocean,” the report concludes. It goes on to add that there is an acute shortage of allopathic doctors and specialists.
Former Union health minister A Ramadoss created a uproar a few years ago when he said that this doctor shortage can be fixed by making it compulsory for young doctors to go to under-served areas. But just sending out a platoon of doctors to all these places and even in under-equipped urban State hospitals is unlikely to change the way things are now because doctors minus proper rural training and infrastructure would be ineffective.
In a recent interview to Hindustan Times, president of the Public Health Foundation of India Dr K Srinath Reddy made a very pertinent point. “Young doctors are mostly trained in medically sophisticated, highly urban, tertiary care institutions. Both in terms of acquired skills and cultural affinity, they are alienated from the rural environment and feel ill-equipped to deal with the health challenges and resource constrained environment of basic health care facilities,” he said. “We need to develop our district hospitals as major training centres for medical and nursing students, with both downstream exposure to primary health systems and upstream exposure to tertiary care”. The practical training has to be mostly location-based in district and sub-district health systems. Further, the government should provide free or heavily subsidised education to locally enrolled students from that state, with a conditionality of service of four years after graduation.
Along with training doctors on rural health and equipping the public health centres better --- not an easy job with the pittance we invest in health care ---- India must leverage technology in a big way to provide the last-mile connectivity. According to a according to a 2012 report by accounting firm PricewaterhouseCoopers most Indians travel about 20 kilometres to reach a hospital but 90% patients don’t need surgery and telemedicine can help them easily.
Early detection can not only cure the patient but also brings down out-of-pocket expenses. In India, there are enough examples of this technology working well. For example, Devi Shetty’s Narayana Health, which pioneered the concept of telemedicine, has one of the largest telemedicine networks in the world.
With nearly 900 million mobile phone connections and over 200 million internet users, experts say wireless technology can be harnessed to decentralise India’s healthcare industry, which is expected to touch $250 billion by 2020.
There are 105 State-funded telemedicine centres in the country. Some states have also individually tied up with private players under the public-private-partnership model. States like Rajasthan are experimenting with the PPP model in health care where private parties will run the state’s PHCs.
In India, a mixed health system has evolved by default and it is loosely governed and inadequately regulated. Moreover, it is ill-equipped to tackle traditional diseases and the new ones effectively. Along with leveraging technology, training and equipping our doctors and frontline health staff such as ASHA workers, the State needs to beef it up to fight old and new challenges. More importantly, it needs to engage stakeholders --- public, private and voluntary sectors - to provide universally accessible, affordable and appropriate health services to all citizens through a well-coordinated Universal Health Coverage policy.