India has to not only increase resources for healthcare but also radically transform the architecture of the country's healthcare delivery system, if the nation is to achieve the government’s vision of assuring health for all, says a paper published in The Lancet on Friday. There are several deficiencies and structural problems with the health-care system that fails to assure health coverage for all in India.
“No government has treated healthcare with the same attention as education,” said Prof. Vikram Patel, the lead of the paper from the Delhi-based Public Health Foundation of India. “There is no ownership of health as a national public good by the medical sector, the government or the civil society.”
“Treating health as a private commodity without adequate checks and balances would result in irrational practices leading to impoverishment,” said Prof. Patel. “Health seen as a private commodity is not consistent with universal health goal.”
It is a fact that a large proportion of the population stands impoverished as a result of high out-of-pocket health-care expenditures and people also suffer the adverse consequences of poor quality of care.
Even today, widespread inequities in health outcomes are seen between and within States, urban and rural population, rich and poor, boys and girls. For instance, infant mortality rates in rural and urban areas differ by 17 points. Nearly 25 per cent of children born to the poorest people are severely malnourished compared with 5 per cent children born to the richest people. A girl born in Madhya Pradesh or Chhattisgarh is five times more likely to die before turning one year compared with a girl born in Kerala. In 2012-13, with varying infant mortality rate even with Assam, a child born in Kokrajhar district in Assam had greater chances of dying than a child born in Dhemaji district.
Despite higher income per head and sustained economic growth for over two decades and substantial improvements in some health indicators in the last decade, India continues to fare badly on many health indicators compared with other middle-income countries and its neighbours like Nepal and Bangladesh.
For instance, India accounted for 20 per cent of the global burden of disease in 2013, as against 21 per cent in 2005. Nearly 27 per cent of all the neonatal deaths and 21 per cent of all deaths in children younger than five years take place in India. Diarrhoea, pneumonia, preterm birth complications, birth asphyxia, and neonatal sepsis are responsible for 68 per cent of all deaths in children of this age group. About 39 per cent of the children in this age group suffer stunting. More than 6 per cent of women are severely undernourished — which is among the highest in low-income and middle-income countries.
India faces a double whammy of communicable and non-communicable diseases. Non-communicable diseases are responsible for 52 per cent of all disease burden and more than 60 per cent of deaths in the country. Nearly 65 per cent of Indians have diabetes. On an average, Indians get their first heart attack when they are 50 years old, at least 10 years earlier than in developed countries.
While ischaemic heart disease, chronic obstructive pulmonary disease, depression, stroke, diabetes, and low back pain were among the leading non-communicable causes disease burden 2013, TB, lower respiratory infections, diarrhoeal diseases, malaria, and typhoid count among the communicable diseases.
According to the authors, the health-care system in India faces seven key challenges — a weak primary health-care sector, unequal distribution of skilled human resources between private and public sectors, unregulated private sector, low public spending on health, irrational and spiralling cost of drugs and technology, weak governance and accountability, and fragmented health information systems.
Primary health-care sector
Though primary health-care infrastructure improved between 2005 and 2015, the expansion in public services has been “inequitably distributed.” “The primary health care is weakening in all States; it is consistently falling. The gravest concern is that the private sector is taking its place,” said Prof. Patel. “The migration of patients to the private sector has still not been stopped.”
About 73 per cent of the public hospital beds are located in the urban areas despite 69 per cent of India’s population residing in rural areas. “There continues to be an overall availability shortfall of 22 per cent of primary health centres, and 32 per cent of community health centres that serve people living in rural areas across the country,” the paper notes. The shortfall in health facilities is felt the most in States like Bihar and Madhya Pradesh.
There is inequitable expansion of public services across India with some States being better off than others. For instance, Goa has one bed per 614 persons while it is one bed for 8,789 persons in Bihar.
Even the quality of care offered in PHCs is uneven and poor. “By the end of March 2015, only 21 per cent of primary health centres and 26 per cent of the community health centres were functioning as per Indian Public Health Standards set by the Health Ministry,” the paper notes. Even the functionality of PHC services is limited by high absenteeism, distant locations and inconvenient timings.
According to the results of the National Sample Surveys on social consumption, there has been a “steady decrease” in the use of public hospitalisation services in the last two decades. The decrease was greater in the urban areas (from 43 per cent in 1995-96 to 32 per cent in 2014) than in rural areas. Use of public services also decreased sharply by the rich both in urban and rural areas.
Skilled human resources
“India does not have an overarching national policy for human resources for health,” notes the paper. Last year only 11.3 per cent of allopathic doctors worked in public sector. Of this, only 3.3 per cent worked in rural areas.
“Community health centres in rural areas of the Indian states of Haryana, Madhya Pradesh, Uttar Pradesh, Chhattisgarh, West Bengal, Gujarat, and Himachal Pradesh, North Eastern States and Jharkhand face shortfalls of specialists exceeding 80 per cent,” the paper highlights.
Unregulated private sector
The private sector has grown and filled the vacuum created by the public sector, which has been unable to expand and meet the demand of the population, both in rural and urban areas. The worrying part is that the private sector is “mostly unregulated.”
“In 2014, more than 70 per cent of outpatient care (72 per cent in the rural areas and 79 per cent in the urban areas) and more than 60 per cent of inpatient care (58 per cent in rural areas and 68 per cent in urban areas) was in the private sector,” the paper notes. The growth has been so much so that between 2002 and 2010, about 70 per cent of increase in hospital beds was met by the private sector.
As a result of the skewed availability of services from the private sector, private practitioners have become the first point of contact for a vast majority of people in India. While the private sector has managed to reach and spread across the country, they have not been able to ensure quality. “Substantial proportion” and in some cases the “majority” of doctors in the private sector are either “unqualified or underqualified.” In rural Madhya Pradesh, only 11 per cent of the health-care providers had a medical degree.
“Informal care providers, with no formal medical training or registration with government for medical practice, are estimated to represent 55 per cent of all providers and are also frequently the first point of contact, especially in rural areas,” the paper notes.
“With few exceptions, the quality of care in the organised private sector also remains suspect,” it warns.
Low public spending on health
The public health expenditure as a proportion of GDP remains at just 1.28 per cent of the country’s GDP in 2013-2014. “The government has to spend more, and more importantly it has to find more imaginative ways of spending the money,” said Prof. Patel.
Although there was plan to increase by 34 per cent every year the Central government’s assistance to State governments for their annual plans in the 12th five year plan, in reality the increase was less than 1 per cent between 2008-2009 and 2012-2013. At the same time, the State government’s expenditure on health shot by 7 per cent. “As a result, the central government’s share in public health expenditure has remained less than 30 per cent since 2010 and has reduced progressively, even if marginally,” it notes.
With States lacking the absorptive capacities and also not spending the allotted money, the actual money released by the Central government to respective States is even less.
The low expenditure by the public sector has in turn led to an increase in out-of-pocket expenditure by the people. “In 2013, out-of-pocket expenditure accounted for about 58 per cent of the total health expenditure on health in the country,” the paper highlights. As a result, in 2011-2012, 55 millions were estimated to have fallen into poverty due to health-care costs.
Several insurance covers provided by the government have helped mitigate the problem. By 2010, close to 25 per cent of the populations has some level of financial protection. But that still leaves a majority without cover.
Spiraling cost of drugs
India spends a meagre 0.1 per cent of GDP on publicly funded drugs, notes the paper. As a result about two-thirds of the total out-of-pocket expenditure is for drugs. The government’s plan to provide 361 generic drugs at affordable cost through government-run pharmacies was to be launched in 2008. By 2012, of the 600 pharmacies that were supposed to be established, only 170 were opened in select States. Of the 170, only 99 were functional in October 2014.
“Tamil Nadu has a central drug procurement system in place and it works excellently,” said Prof. Patel. Rajasthan too has implemented the provision of free essential medicines in the public system.
The paper outlines a three point action plan to both combat and counter these constraints and weaknesses facing India’s health sector. First, there is low public spending on health and “stagnation” in public spending in the past decade. “There is an absence of political will to give primacy to health in India’s development agenda and a belief that economic growth by itself will lead to sufficient health gains,” the paper notes. Second, trust and engagement between various health care sectors is simply missing. Third, the health care sector is fragmented with poor coordination between central and state governments.
“At the heart of these constraints is the apparent unwillingness on the part of the state to prioritise health as a fundamental public good, central to India’s developmental aspirations, on par with education,” the authors write.
