Hardly five years ago, when multi-discipline hospitals started mushrooming in cities across the country, thanks to liberal support from the governments under the policy of privatisation and liberalisation, rising India celebrated their arrival. Many believed their arrival was a landmark in the history of health care in India. There was, further, the aspect of medical tourism. In sum, this was seen as the end of the search for a cost-effective and modern private medical service, with particular significance for the secondary and tertiary sectors.
The mainstream media, seeing this as a signal development, extended their support full-throatedly. The large scope for health care advertisements could have influenced their judgment in several instances. The dailies, the periodicals, and television went with the flow, eulogising the new arrivals and the trend.
But what about accessible, affordable, and quality healthcare for the non-privileged?
Two recent reports relevant to public health – the World Health Report 2010 (WHR 2010) of the World Health Organisation, and the Annual Report to the People on Health 2010 of the Ministry of Health and Family Welfare, Government of India – have revived the debate on the vital need for a universal health care system. It bears recall that a commitment was made five years ago by the member-states of WHO to realise in their countries the objective of Health for All by 2020.
The WHO, an active wing of the United Nations Organisation, estimated that a billion people round the world could not afford any health care services at all, and that every year one hundred million people were pushed into extreme poverty after paying huge sums as fees and related charges for medical treatment. While releasing the report, WHO Director-General Margaret Chan declared that WHR 2010 aimed to put more countries on the path to universal health care coverage. She noted: “Access to basic health care is a fundamental human right, as stated in the WHO Constitution, and not just a privilege to be enjoyed in a few wealthy societies.”
The report says that all countries, rich and poor, could do more in respect of getting universal health care coverage. It wants them to think of ways to increase efficiency, plan new taxes, and take innovative fund-raising steps to improve access to health care.
The WHR proposes that member-countries can raise more funds and reduce financial barriers with a view to boosting income so as to spend on health care. The report points out that 20 per cent to 40 per cent of the expenditure was wasted through the purchase of unnecessary drugs, hospital-related inefficiency, and so on. The recommendation is that the total out-of-pocket payment by patients should not exceed 15 per cent to 20 per cent of the country's total spending on the patients treated.
The WHO report suggests that governments can increase their spending capacity by going in for special taxation. Other suggestions include finding diverse sources of revenue from levies like ‘sin' taxes on products such as tobacco and alcohol and tax on transactions. The report notes, for example, that if India were to impose a levy of 0.005 per cent on foreign exchange transactions, the government could raise $370 million a year.
Constraints and confessions
The second document, the Annual Report to the People on Health, which was published in September 2010, begins, understandably, with listing the achievements of the Indian government in the health sector. In terms of life expectancy, child survival, and reducing maternal mortality, the report notes, India's performance has improved steadily. Life expectancy at birth now is 63.5 years; the infant mortality rate is 53 per 1000 live births; and the maternal mortality rate is 254 per 100,000 live births. The report, however, calls attention to the wide variations across States in the improvement of these key human development indicators, and to the “inequities based on urban divides, gender imbalances, and caste patterns.”
The performance of the National Rural Health Mission (NRHM), which was launched in 2005 with a special focus on 18 States, including eight Empowered Action Group States (Jammu and Kashmir, Himachal Pradesh, and the North-Eastern States), is commended. The promise is that there will be a policy shift towards addressing inequities through a special focus on inaccessible and difficult areas and districts where health performance is abysmal.
As for the question of accessibility, the central government's report reiterates that “the government's mandate [is] to shape, strengthen, support and sustain a health system where every citizen had access to readily available, qualitatively appropriate and adequately wide ranging health services at affordable costs.” A “major constraint in achieving universal access to health services,” it emphasises, is “the non-availability of skills and trained human resources.” It admits “by international standards, India fares very poorly, calling for strong remedial action.” The report also recognises the obvious, namely that bringing about universal access to decent health care and medical facilities is more than finding ways and means to overcome the financial crunch.
Private sector dominance
But what about the contribution made by private medical care? The Annual Report to the People on Health for 2010 makes a clean breast of the many hurdles before the Health Ministry when it comes to putting in place a system that can provide universal access to health care. The foremost of the problems is the very large presence of the private sector in the health industry and its consequences. As the report puts it: “At the time of Independence only about 8 per cent of all qualified modern medical care was provided by the private sector. But over the years the share of the private sector in the provision of health care has increased to about 80 per cent of all out-patient care and about 60 per cent of all in-patient care.”
Further, “the private sector in India has a dominant presence in all the sub-markets such as medical education and training, medical technology and drugs and pharmaceutical manufacture and sale, hospital construction and ancillary services and finally, the provisioning of medical care.” In fact, more than 75 per cent of the human resources and advanced medical technology, 68 per cent of an estimated 15,097 hospitals and 37 per cent of 6,23,819 total beds in the country are in the private sector, most of which is located in urban areas.
“The private sector's prominence in the health sector,” the government report concludes, “has led to inequities in access to health care.” Such a predominant presence of the private sector in the medical filed would naturally lead to an exodus of highly qualified medical and para-medical personnel (most of whom have been trained in government-run medical institutions) from government service to hospitals run by corporates, which have mushroomed with government support.
This has driven government-run hospitals in several places to conditions worse than before. The growth of medical tourism has also had a negative impact on the poor and needy accessing quality treatment at affordable price. In most Indian States, after two decades of such developments decent health care, particularly at the secondary and tertiary levels, is beyond the reach of the poor.
It is the social responsibility of the news media, especially mainstream newspapers, to be an active part of the national agenda of rescuing the Indian public health care system, strengthening it, and, if necessary, re-inventing it so that it can meet the needs of the hundreds of millions of the health-deprived.