Is India doing enough for public health?
Each year, 40 million people are pushed into poverty because they are forced to abandon jobs because of ill health or have to sell their land and assets to pay healthcare costs.
India’s the pharmacy of the world, manufacturing 60% of the world’s life-saving vaccines and close to half of its generic drugs. Its skilled medical professionals and technically-advanced hospitals have made it one among the world’s top five medical tourists destinations, where close to 2 lakh overseas patients arrive each year seeking high-quality, low-cost treatment and care.
Yet, it faces mindboggling shortfalls in healthcare delivery to its own populations, forcing millions to seek treatment in the private sector. As much as 70% of India’s health spending is out-of-pocket, with the private clinics and hospitals providing 80% outpatient and 60% inpatient treatment. With regulation varying widely across states, this treatment is often inadequate and inappropriate, and almost always unaffordable.
India’s government spending on health is among the lowest in the world. Of the total health spending of 4.1% of the GDP (2012), the government spends just 1.16%, compared to 2.9% in China and 4.1% in Brazil. In the US, government spend is 8.3% of the total 16.9% of the GDP spent on healthcare.
As a result, the out-of-pocket expenditure is three to four times more than public spend, except for some union territories and the states of Arunachal Pradesh, Jammu & Kashmir, Mizoram, Nagaland and Sikkim. Each year, 40 million people are pushed into poverty because they are forced to abandon jobs because of ill health or have to sell their land and assets to pay healthcare costs. With more than 9 in 10 people self-employed, private and employer-provided health insurance covers only a fraction of the population.
Money for nothing
Financing new investments in public health is the easy bit. The real challenge is creating human resources and new infrastructure needed to meet the health needs of a growing population.
India’s among the biggest exporter of skilled surgeons and trained nurses, yet its doctor-patient ratio is among the worst in the world.
The human resources in health shortfall is expected to almost double to from 35.9 lakh in 2013 to 74 lakh by 2022, said the National Skill Development Corporation (NSDC) this week, even as the size of the healthcare sector grows to Rs 9.64 lakh crore by 2017.
There’s one doctor available for a population of more than 1,200 people, shows data from the National Health Profile 2013. What’s worrying is that this number includes 7.5 lakh practitioners of alternative systems of medicine referred to as AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy), who are not licensed to perform lifesaving procedures and surgeries.
This means that if you live in a village or small town and need emergency surgery, the doctor closest to you is very likely to be one who can do little more than refer you to a district government hospital.
Crowded out
As it is, government hospitals are overcrowded and lack resources to meet the growing demand for services. To treat a population of one and a quarter billion, India has less than 20,000 hospitals and 6.28 lakh beds, only a third of which are in rural areas. On average, there one bed serves almost 2,000, while each hospital serves an average population of more than 60,000, up from 50,000 people per hospital in 2012.
India has 356 registered medical colleges that train close to 45,000 students at the undergraduate level and about 24,000 students at the post-graduate level. The Medical Council of India (MCI) has recommended adding MBBS seats, but adding seats and setting up colleges –regional All India Institutes of Medical Sciences (AIIMS) and government medical colleges -- is not enough. It’s hard to come by teachers to train young doctors in practical skills that cannot be learned by rote alone.
Free for all
Under the Centre’s National Health Assurance Mission, the Centre has promised more than 50 free drugs, a dozen diagnostic tests and insurance cover to all. The first phase of the Rs 160,000 crore programme is being rolled out and it is expected to cover the entire population by 2019. The initiative, which drew positive comparisons with ObamaCare, is expected to push up India’s public health spending to acceptable levels.
If implemented efficiently, it has the potential change people’s lives. There is enough data on the successes of similar localized programmes. Late last year, the British Medical Journal reported that the Vajpayee Arogyashree Scheme, which provided health insurance for catastrophic illnesses to households below the poverty line in Karnataka, lowered death by 64% and halved out-of-pocket spending on hospitalizations. The study covered nearly 80,000 households in more than 600 villages.
While providing free essential drugs and diagnostics is a start, it cannot happen in isolation. You need infrastructure, manpower and resources to support delivery, and clear targets and data for course correction.