The World Health Organization (WHO) has described the framework of a health care system in terms of its basic building blocks. These include “delivery of effective, safe, quality personal and non-personal interventions; a healthcare workforce that is adequate in numbers , completely trained and fairly distributed; a health information system that produces, analyses and disseminates reliable and timely intervention, medical products and technologies that are safe and efficacious, cost effective and accessible; a financing system that raises adequate funds to ensure the population can use needed services and is protected from financial catastrophe; and governance and oversight of the above.”
Lawton Robert Burns, the editor of this book which has chapters by well-known experts in various aspects of a healthcare system, ventures to apply all these parameters to study the Indian Healthcare Industry and the result is this robust volume under review. A comparison between the U.S., India and China becomes inevitable in a study of this nature and the editor brings out several salient yet contrasting features the way healthcare is managed in these countries.
While the U.S. spends a whopping 17 per cent of its GDP on healthcare, India spends a measly 4 per cent. Compared to the U.S., where the government accounts for nearly half of national health expenditures, Central and State governments in 'socialist' India account only for a little more than one-fourth of the total spending on healthcare. If we factor in the gross regional variations and societal inequities in resource allocation and access to healthcare in India, it would not be difficult to understand the overall scenario of operational deficiencies of the system available in the country. Not surprising also is the fact that India is saddled with a large share of global burden of maternal health [19 per cent], undernourished children [33 per cent], neonatal death [29-30 per cent], under vaccinated children [37-44 per cent], leprosy [50 per cent] and TB [25-26 per cent] .
On the other hand, we have some of the world class medical facilities attracting a considerable number of medical tourists seeking and getting very high quality medical care at a fraction of the cost compared to the U.S.
The comparison with China is equally interesting; both countries emerged out of colonialism at roughly the same time; both have healthcare written into their Constitution; both governments assume a small share of total health care spending and require their populations to bear a huge percentage of total healthcare costs by paying out of pocket for services. Both countries have a three-tiered structure of care delivery to a largely rural population.
And in both countries, there is this classic ‘double disease burden’ of Communicable and Non-Communicable diseases. Yet, India’s IMR [47 per thousand; 2011 data] is more than double that of China. So is the percentage of birth by skilled attendants [97 per cent in China versus 43-58 percent in India].
India, as well as every other country faces this huge dilemma of “Iron Triangle” whose three angles are formed by Efficiency, High Quality and Patient Access. As the editor points out, efforts to widen any one angle inevitably results in the narrowing of the other two angles. That India is trying hard to keep all the three angles balanced is a fact that comes out while reading this book.
Drawing from the WHOs definition of a healthcare system, the editor divides the book into 3 major parts. The first part discusses the role of providers. After an extensive discussion on the medical professionals of India, which includes medical colleges, supply and migration of medical and para medical personnel and emergence of super specialities , the editor goes on to discuss various hospital models available in India.
The chapters dealing with Aravind Eye Care System, L.V.Prasad Eye Institute, Vatsalya Healthcare as well as corporate hospital models like the Apollo Hospitals, make for excellent reading and are very useful to those involved in planning hospitals in India. Also included are some of the outstanding grass root health care models like SEARCH [Society for Education, Action and Research in Community Health] in Maharashtra and Jan Swastha Sahyog [JSS] in Chhattisgarh. The JSS model of detecting anaemia for Re. 1 and diabetes for Rs. 2 and pregnancy for Rs. 3 and sterile delivery kit, very vital for ensuring safe delivery, for Rs. 40 is something for our planners to study in detail and scale up nationally.
The second section on payers deals extensively with the financing of healthcare services. The chapter on health insurance brings out the emerging challenges in this sector. It is a fact that more than 70 per cent of the healthcare expenses are out-of-pocket, a major section of which goes towards out-patient consultation and purchase of drugs, both of which are not covered by the insurance sector at present.
The healthcare expenditures are a leading cause of household debt and more than 40 per cent of the hospitalised patients are forced to borrow money or sell assets which average 58 per cent of their annual expenditures. Given this setting, providing insurance cover to all those who are vulnerable and covering their out-patient costs as well as the cost of drugs and implants is a daunting task for a big country like India. Neil Parikh and Vimala Ramachandran discuss various available insurance models including those offered by the Central and various State governments. Aman Kumar discusses the future prospects of private equity in this sector which is worth around $76-78 billion, and projected to grow at around 15 per cent compound annual growth rate.
The last section deals with producers of drugs, medical devices and various products of biotechnology like vaccines, Insulin etc. Viswas Seshadri’s chapter on Indian Pharmaceutical Sector is a must read for all practitioners of medicine.
On the whole, this is a very useful compendium on one of the most vital, fast growing industrial sectors which touches the lives of everyone — you and me included.